Aims. The aims of this study were to describe the demographic, socioeconomic, and educational factors associated with core surgical trainees (CSTs) who apply to and receive offers for higher surgical training (ST3) posts in Trauma & Orthopaedics (T&O). Methods. Data collected by the UK Medical Education Database (UKMED) between 1 January 2014 and 31 December 2019 were used in this retrospective longitudinal cohort study comprising 1,960 CSTs eligible for ST3. The primary outcome measures were whether CSTs applied for a T&O ST3 post and if they were subsequently offered a post. A directed acyclic graph was used for detecting confounders and adjusting logistic regression models to calculate odds ratios (ORs), which assessed the association between the primary outcomes and relevant exposures of interest, including: age, sex, ethnicity, parental socioeconomic status (SES), domiciliary status, category of medical school, Situational Judgement Test (SJT) scores at medical school, and success in postgraduate examinations. This study followed STROBE guidelines. Results. Compared to the overall cohort of CSTs, females were significantly less likely to apply to T&O (OR 0.37, 95% CI 0.30 to 0.46; n = 155/720 female vs n = 535/1,240 male; p < 0.001). CSTs who were not UK-domiciled prior to university were nearly twice as likely to apply to T&O (OR 1.99, 95% CI 1.39 to 2.85; n = 50/205 vs not UK-domiciled vs n = 585/1,580 UK-domiciled; p < 0.001). Age, ethnicity, SES, and medical school category were not associated with applying to T&O. Applicants who identified as ‘black and minority ethnic’ (BME) were significantly less likely to be offered a T&O ST3 post (OR 0.70, 95% CI 0.51 to 0.97; n = 165/265 BME vs n = 265/385 white; p = 0.034). Differences in age, sex, SES, medical school category, and SJT scores were not significantly associated with being offered a T&O ST3 post. Conclusion. There is an evident disparity in sex between T&O applicants and an ethnic disparity between those who receive offers on their first attempt. Further high-quality, prospective research in the post-COVID-19 pandemic period is needed to improve equality, diversity, and inclusion in T&O training. Cite this article: Bone Jt Open 2024;5(8):697–707

Aims. Arthroplasty skills need to be acquired safely during training, yet operative experience is increasingly hard to acquire by trainees. Virtual reality (VR) training using headsets and motion-tracked controllers can simulate complex open procedures in a fully immersive operating theatre. The present study aimed to determine if trainees trained using VR perform better than those using conventional preparation for performing total hip arthroplasty (THA). Patients and Methods. A total of 24 surgical trainees (seven female, 17 male; mean age 29 years (28 to 31)) volunteered to participate in this observer-blinded 1:1 randomized controlled trial. They had no prior experience of anterior approach THA. Of these 24 trainees, 12 completed a six-week VR training programme in a simulation laboratory, while the other 12 received only conventional preparatory materials for learning THA. All trainees then performed a cadaveric THA, assessed independently by two hip surgeons. The primary outcome was technical and non-technical surgical performance measured by a THA-specific procedure-based assessment (PBA). Secondary outcomes were step completion measured by a task-specific checklist, error in acetabular component orientation, and procedure duration. Results. VR-trained surgeons performed at a higher level than controls, with a median PBA of Level 3a (procedure performed with minimal guidance or intervention) versus Level 2a (guidance required for most/all of the procedure or part performed). VR-trained surgeons completed 33% more key steps than controls (mean 22 (. sd. 3) vs 12 (. sd. 3)), were 12° more accurate in component orientation (mean error 4° (. sd. 6°) vs 16° (. sd. 17°)), and were 18% faster (mean 42 minutes (. sd. 7) vs 51 minutes (. sd. 9)). Conclusion. Procedural knowledge and psychomotor skills for THA learned in VR were transferred to cadaveric performance. Basic preparatory materials had limited value for trainees learning a new technique. VR training advanced trainees further up the learning curve, enabling highly precise component orientation and more efficient surgery. VR could augment traditional surgical training to improve how surgeons learn complex open procedures. Cite this article: Bone Joint J 2019;101-B:1585–1592

Freehand distal interlocking of intramedullary nails remains a challenging task. If not performed correctly it can be a time consuming and radiation expensive procedure. Recently, the AO Research Institute developed a new training device for Digitally Enhanced Hands-on Surgical Training (DEHST) that features practical skills training augmented with digital technologies, potentially improving surgical skills needed for distal interlocking. Aim of the study: To evaluate weather training with DEHST enhances the performance of novices without surgical experience in free-hand distal nail interlocking compared to a non-trained group of novices. 20 novices were assigned in two groups and performed distal interlocking of a tibia nail in an artificial bone model. Group 1: DEHST trained novices (virtual locking of five nail holes during one hour of training). Group 2: untrained novices without DEHST training. Time, number of x-rays, nail hole roundness, critical events and success rates were compared between the groups. Time to complete the task (sec.) and x-ray exposure (µGcm2) were significantly lower in Group1 414.7 (290–615) and 17.8 (9.8–26.4) compared to Group2 623.4 (339–1215) and 32.6 (16.1–55.3); p=0.041 and 0.003. Perfect circle roundness (%) was 95.0 (91.1–98.0) in Group 1 and 80.8 (70.1–88.9) in Group 2; p<0.001. In Group 1 90% of the participants achieved successful completion of the task (hit the nail with the drill), whereas only 60% of the participants in group 2 achieved this; p=0.121. Training with DEHST significantly enhances the performance of novices without surgical experience in distal interlocking of intramedullary nails. Besides radiation exposure and operation time the com-plication rate during the operation can be significantly reduced

Evidence supporting the use of virtual reality (VR) training in orthopaedic procedures is rapidly growing. However, the impact of the timing of delivery of this training is yet to be tested. We aimed to investigate whether spaced VR training is more effective than massed VR training. 24 medical students with no hip arthroplasty experience were randomised to learning the direct anterior approach total hip arthroplasty using the same VR simulation, training either once-weekly or once-daily for four sessions. Participants underwent a baseline physical world assessment on a saw bone pelvis. The VR program recorded procedural errors, time, assistive prompts required and hand path length across four sessions. The VR and physical world assessments were repeated at one-week, one-month, and 3 months after the last training session. Baseline characteristics between the groups were comparable (p > 0.05). The daily group demonstrated faster skills acquisition, reducing the median ± IQR number of procedural errors from 68 ± 67.05 (session one) to 7 ± 9.75 (session four), compared to the weekly group's improvement from 63 ± 27 (session one) to 13 ± 15.75 (session four), p < 0.001. The weekly group error count plateaued remaining at 14 ± 6.75 at one-week, 16.50 ± 16.25 at one-month and 26.45 ± 22 at 3-months, p < 0.05. However, the daily group showed poorer retention with error counts rising to 16 ± 12.25 at one-week, 17.50 ± 23 at one-month and 41.45 ± 26 at 3-months, p<0.01. A similar effect was noted for the number of assistive prompts required, procedural time and hand path length. In the real-world assessment, both groups significantly improved their acetabular component positioning accuracy, and these improvements were equally maintained (p<0.01). Daily VR training facilitates faster skills acquisition; however weekly practice has superior skills retention

Background. Training within surgery is changing from the traditional Halstedian apprenticeship model. There is need for objective assessment of trainees, especially their technical skills, to ensure they are safe to practice and to highlight areas for development. In addition, due to working time restrictions in both the UK and the US, theatre time is being limited for trainees, reducing their opportunities to learn such technical skills. Simulation is one adjunct to training that can be utilised to both assess trainees objectively, and provide a platform for trainees to develop their skills in a safe and controlled environment. The insertion of a dynamic hip screw (DHS) relies on complex psychomotor skills to obtain an optimal implant position. The tip-apex distance (TAD) is a measurement of this positioning, used to predict failure of the implant. These skills can be obtained away from theatre using workshop bone simulation, however this method does not utilise fluoroscopy due to the associated radiation risks. FluoroSim is a novel digital fluoroscopy simulator that can recreate digital radiographs with workshop bone simulation for the insertion of a DHS guide-wire. In this study, we present the training effect demonstrated on FluoroSim. The null hypothesis states that no difference will be present between users with different amounts of exposure to FluoroSim. Methods. Medical students were recruited from three London universities and randomised into a training (n=23) and a control (n=22) cohort. All participants watched a video explanation of the simulator and task and were blinded to their allocation. Training participants completed 10 attempts in total, 5 attempts in week one, followed by a one week wash out period, followed by 5 attempts in week 2. The control group completed a single attempt each week. For each attempt, 5 metrics were recorded; TAD, procedural time, number of radiographs, number of guide-wire retires and cut-out rate (COR). Results. No significant difference was present for any metric between the groups at baseline; randomisation had produced heterogeneous groups minimising selection bias. Intragroup training effect (comparison of initial and last attempt) was significant for all metrics in the training group (p < 0.05) but for no metrics in the control group. The intergroup training effect (comparison of training group attempt ten to control group attempt ten) was present for procedural time, number of radiographs and number of guide-wire retries (p < 0.05). Significance was not reached for TAD and COR. Conclusion. FluoroSim shows skill acquisition with repeat exposure, so the null hypothesis can be rejected. This study has demonstrated the merits of FluoroSim as a training adjunct for psychomotor skill development in a DHS setting

Aims. Global literature suggests that female surgical trainees have lower rates of independent operating (operative autonomy) than their male counterparts. The objective of this study was to identify any association between gender and lead/independent operating in speciality orthopaedic trainees within the UK national training programme. Methods. This was a retrospective case-control study using electronic surgical logbook data from 2009 to 2021 for 274 UK orthopaedic trainees. Total operative numbers and level of supervision were compared between male and female trainees, with correction for less than full-time training (LTFT), prior experience, and time out during training (OOP). The primary outcome was the percentage of cases undertaken as lead surgeon (supervised and unsupervised) by UK orthopaedic trainees by gender. Results. All participants gave permission for their data to be used. In total, 274 UK orthopaedic trainees submitted data (65% men (n = 177) and 33% women (n = 91)), with a total of 285,915 surgical procedures logged over 1,364 trainee-years. Males were lead surgeon (under supervision) on 3% more cases than females (61% (115,948/189,378) to 58% (50,285/86,375), respectively; p < 0.001), and independent operator (unsupervised) on 1% more cases. A similar trend of higher operative numbers in male trainees was seen for senior (ST6 to 8) trainees (+5% and +1%; p < 0.001), those with no time OOP (+6% and +8%; p < 0.001), and those with orthopaedic experience prior to orthopaedic specialty training (+7% and +3% for lead surgeon and independent operator, respectively; p < 0.001). The gender difference was less marked for those on LTFT training, those who took time OOP, and those with no prior orthopaedic experience. Conclusion. This study showed that males perform 3% more cases as the lead surgeon than females during UK orthopaedic training (p < 0.001). This may be due to differences in how cases are recorded, but must engender further research to ensure that all surgeons are treated equitably during their training. Cite this article: Bone Joint J 2023;105-B(7):821–832

Aims. Mechanical stimulation is a key factor in the development and healing of tendon-bone insertion. Treadmill training is an important rehabilitation treatment. This study aims to investigate the benefits of treadmill training initiated on postoperative day 7 for tendon-bone insertion healing. Methods. A tendon-bone insertion injury healing model was established in 92 C57BL/6 male mice. All mice were divided into control and training groups by random digital table method. The control group mice had full free activity in the cage, and the training group mice started the treadmill training on postoperative day 7. The quality of tendon-bone insertion healing was evaluated by histology, immunohistochemistry, reverse transcription quantitative polymerase chain reaction, Western blotting, micro-CT, micro-MRI, open field tests, and CatWalk gait and biomechanical assessments. Results. Our results showed a significantly higher tendon-bone insertion histomorphological score in the training group, and the messenger RNA and protein expression levels of type II collagen (COL2A1), SOX9, and type X collagen (COL10A1) were significantly elevated. Additionally, tendon-bone insertion resulted in less scar hyperplasia after treadmill training, the bone mineral density (BMD) and bone volume/tissue volume (BV/TV) were significantly improved, and the force required to induce failure became stronger in the training group. Functionally, the motor ability, limb stride length, and stride frequency of mice with tendon-bone insertion injuries were significantly improved in the training group compared with the control group. Conclusion. Treadmill training initiated on postoperative day 7 is beneficial to tendon-bone insertion healing, promoting biomechanical strength and motor function. Our findings are expected to guide clinical rehabilitation training programmes. Cite this article: Bone Joint Res 2023;12(5):339–351

Aims. To evaluate if, for orthopaedic trainees, additional cadaveric simulation training or standard training alone yields superior radiological and clinical outcomes in patients undergoing dynamic hip screw (DHS) fixation or hemiarthroplasty for hip fracture. Methods. This was a preliminary, pragmatic, multicentre, parallel group randomized controlled trial in nine secondary and tertiary NHS hospitals in England. Researchers were blinded to group allocation. Overall, 40 trainees in the West Midlands were eligible: 33 agreed to take part and were randomized, five withdrew after randomization, 13 were allocated cadaveric training, and 15 were allocated standard training. The intervention was an additional two-day cadaveric simulation course. The control group received standard on-the-job training. Primary outcome was implant position on the postoperative radiograph: tip-apex distance (mm) (DHS) and leg length discrepancy (mm) (hemiarthroplasty). Secondary clinical outcomes were procedure time, length of hospital stay, acute postoperative complication rate, and 12-month mortality. Procedure-specific secondary outcomes were intraoperative radiation dose (for DHS) and postoperative blood transfusion requirement (hemiarthroplasty). Results. Eight female (29%) and 20 male trainees (71%), mean age 29.4 years, performed 317 DHS operations and 243 hemiarthroplasties during ten months of follow-up. Primary analysis was a random effect model with surgeon-level fixed effects of patient condition, patient age, and surgeon experience, with a random intercept for surgeon. Under the intention-to-treat principle, for hemiarthroplasty there was better implant position in favour of cadaveric training, measured by leg length discrepancy ≤ 10 mm (odds ratio (OR) 4.08 (95% confidence interval (CI) 1.17 to 14.22); p = 0.027). There were significantly fewer postoperative blood transfusions required in patients undergoing hemiarthroplasty by cadaveric-trained compared to standard-trained surgeons (OR 6.00 (95% CI 1.83 to 19.69); p = 0.003). For DHS, there was no significant between-group difference in implant position as measured by tip-apex distance ≤ 25 mm (OR 6.47 (95% CI 0.97 to 43.05); p = 0.053). No between-group differences were observed for any secondary clinical outcomes. Conclusion. Trainees randomized to additional cadaveric training performed hip fracture fixation with better implant positioning and fewer postoperative blood transfusions in hemiarthroplasty. This effect, which was previously unknown, may be a consequence of the intervention. Further study is required. Cite this article: Bone Jt Open 2023;4(8):602–611

Musculoskeletal (MSK) disorders continue to be a major cause of pain and disability worldwide. The mission statement of the Canadian Orthopaedic Association (COA) is to “promote excellence in orthopaedic and musculoskeletal health for Canadians,” and orthopaedic surgeons serve as leaders in addressing and improving musculoskeletal health. However, patients with MSK complaints most commonly present first to a primary care physician. According to a survey of family physicians in British Columbia, 13.7-27.8% of patients present with a chief complaint that is MSK-related (Pinney et Regan, 2001). Therefore, providing excellent MSK care to Canadians requires that all physicians, especially those involved in primary care, be adequately trained to diagnose and treat common MSK conditions. To date, there has been no assessment of the total mandatory MSK training Canadian family medicine residents receive. It is also unclear, despite the prevalence of MSK complaints among Canadian patients, if current family physicians are competent or confident in their ability to provide fundamental MSK care. The purpose of this study is to determine the amount of mandatory MSK training Canadian family medicine residents are currently receiving. Web-based research was used to determine how many weeks of mandatory MSK training was incorporated into current Canadian family medicine residency training programs. This information was gathered from either the Canadian Resident Matching Service website (carms.ca) or the residency program's individual website. If this information was not available on a program's website, a program administrator was contacted via email in order to ascertain this information directly. MSK training was considered to be any rotation in orthopaedic surgery, spine surgery, sports medicine, or physiatry. 156 Canadian family medicine residency training sites were identified. Information pertaining to mandatory MSK education was collected for 150 sites (95.5%). Of the 150 training sites, 102(68 %) did not incorporate any mandatory MSK training into their curriculum. Of the 48 programs that did, the average number of weeks of MSK training was 3.37 weeks. 32/48 programs (66.7%) included 4 weeks of MSK training, which represents 3.8% of a 2-year training program. Current Canadian family medicine residents are not receiving sufficient musculoskeletal training when compared to the overall frequency of musculoskeletal presentations in the primary care setting. Understanding current family medicine physicians’ surveyed confidence and measured competence with respect to diagnosing and treating common musculoskeletal disorders could also prove helpful in demonstrating the need for increased musculoskeletal education. Future orthopaedic initiatives could help enhance family medicine MSK training

The imminent introduction of the new Trauma & Orthopaedic (T&O) curriculum, and the implementation of the Improving Surgical Training initiative, reflect yet another paradigm shift in the recent history of trauma and orthopaedic training. The move to outcome-based training without time constraints is a radical departure from the traditional time-based structure and represents an exciting new training frontier. This paper summarizes the history of T&O training reform, explains the rationale for change, and reflects on lessons learnt from the past. Cite this article: Bone Jt Open 2021;2-3:181–190

Previous Anterior Cruciate Ligament (ACL) reconstruction is currently a bar from entry to the Royal Marines and Royal Navy, whilst the British Army allows recruits to join if asymptomatic 18 months post ACL reconstruction. However current Royal Marines policy is to rehabilitate recruits who sustain an ACL disruption in training. We retrospectively analysed the rehabilitation times and pass out rate of Royal Marines who had an ACL disruption during recruit training over an 8 year period. 12 recruits sustained an ACL disruption during recruit training in the study period, giving an incidence of around 1.5/1000 recruits. 9 Patients underwent ACL repairs in training, with 1 patient leaving and rejoining post repair and later successfully passed out. 2 patients were treated conservatively. Of the 12 ACL sustained in training 8/12 (67%) passed out. None of the patients treated conservatively passed out. The mean time out of training for successful recruits was 51.6 weeks (95% CI 13.1) mean rehabilitation time post ACL reconstruction for successful recruits was 36.7 weeks (95% CI 12.5). Mean time to discharge for unsuccessful recruits 63.2 weeks (95% CI 42.4). In the operative group 1/10 left due to failure to return to training and 1/10 left through unrelated reasons. Current costing for recruit training is £1800 per week per recruit. ACL injuries are not common in Royal Marine Training, and reconstruction is not a bar to completing Royal Marine basic training. We estimate that it costs around £100,000 per-injured recruit, to maintain a policy of rehabilitating ACL injured recruits in Royal Marines training. Further research into the long-term employability or Royal Marines sustaining an ACL injury in training is required

Aims. The decrease in the number of satellite cells (SCs), contributing to myofibre formation and reconstitution, and their proliferative capacity, leads to muscle loss, a condition known as sarcopenia. Resistance training can prevent muscle loss; however, the underlying mechanisms of resistance training effects on SCs are not well understood. We therefore conducted a comprehensive transcriptome analysis of SCs in a mouse model. Methods. We compared the differentially expressed genes of SCs in young mice (eight weeks old), middle-aged (48-week-old) mice with resistance training intervention (MID+ T), and mice without exercise (MID) using next-generation sequencing and bioinformatics. Results. After the bioinformatic analysis, the PI3K-Akt signalling pathway and the regulation of actin cytoskeleton in particular were highlighted among the top ten pathways with the most differentially expressed genes involved in the young/MID and MID+ T/MID groups. The expression of Gng5, Atf2, and Rtor in the PI3K-Akt signalling pathway was higher in the young and MID+ T groups compared with the MID group. Similarly, Limk1, Arhgef12, and Araf in the regulation of the actin cytoskeleton pathway had a similar bias. Moreover, the protein expression profiles of Atf2, Rptor, and Ccnd3 in each group were paralleled with the results of NGS. Conclusion. Our results revealed that age-induced muscle loss might result from age-influenced genes that contribute to muscle development in SCs. After resistance training, age-impaired genes were reactivated, and age-induced genes were depressed. The change fold in these genes in the young/MID mice resembled those in the MID + T/MID group, suggesting that resistance training can rejuvenate the self-renewing ability of SCs by recovering age-influenced genes to prevent sarcopenia. Cite this article: Bone Joint Res 2022;11(2):121–133

Background. Musculoskeletal disorders, including low back pain, affects 68% of UK physiotherapists across their career with patient handling considered a key risk factor. Manual handling training is mandatory for all allied health professionals, however there is limited research investigating whether professionals adopt recommended manual handling principles following training. Purpose of Study. To investigate spinal angles when facilitating sit-to-stand, and a turning manoeuvre in bed, comparing first-year physiotherapy students (who have not received manual handling training) with final-year physiotherapy students (who have received manual handling training). Methods. Cross-sectional pilot study (n= 20; 10 first-year, 10 final-year). All participants were exposed to a short training video outlining how to safely perform each manoeuvre. Retroreflective markers were attached to: L4, ASIS, PSIS, T12, C7, tragus and canthus. Spinal (neck, thoracic, lumbar and pelvic) angles were established via digital photographs using a bespoke MATLAB programme (MathWorks). A Mann-Whitney U test was conducted to determine between group differences. Results. No statistically significant results were observed between first-year and final-year students for both manoeuvres (p<0.05), except for neck angle during the turning manoeuvre (final-year students demonstrating more upright postures, p=0.037). Interestingly, for the turning manoeuvre in bed it was noted that none of the participants adjusted the bed height. Conclusion. The results suggest that clinical experience and routine manual handling training may not have a significant effect on spinal posture, especially in relation to pelvic, lumbar and thoracic angles. Further work is needed to understand how training relates to adoption of manual handling principles in practice. Conflicts of interest. None. Sources of funding. None

Orthopaedic surgery is a practical surgical specialization field, the exit exam for registrars remains written and oral. Despite logbook evaluation and surgical work-based assessments, the question remains: can registrars perform elective surgery upon qualification? In South Africa, obstacles to elective surgical training include the trauma workload, financial constraints, fellowships and the Covid pandemic. In hip and knee arthroplasty, new approaches like the direct anterior approach (DAA) and robotic-assisted knee surgery also contributed to the dilution of cases available for registrar training. There are concerns that orthopaedic registrars do not perform enough cases to achieve surgical proficiency. Review of the last 4 years of registrar logbooks in hip and knee arthroplasty surgery performed in a single tertiary academic hospital in South Africa. We included all primary total hip replacements (THR), total knee replacements (TKR) and hemiarthroplasties (HA) done for neck of femur (NOF) fractures between 1 April 2019 and 30 March 2023. Differentiation between registrar assisting, registrar performing with consultant supervision and registrar performing independent surgery was done. 990 hip arthroplasties (472 Primary THR, 216 NOF THR, 302 NOF HA) and 316 Primary TKR were performed during the study period. In primary elective THR the posterior approach was dominant and used in 76% of cases. In NOF THA the DAA was dominant used in 98% of cases. Primary TKR robotic-assisted technologies was used in 27% (n=94) cases. Registrars as the primary surgeon were the highest in NOF THA at 70% of cases and the lowest performing TKR at 25%. During 3-month rotations, an average registrar performed 12 (2 TKR and 10 THR) and assisted in 35 (10 TKR and 25 THR) cases. Despite the large number of arthroplasties operations being performed over the last 4-year period, the surgical cases done by registrars are below, the proposed minimal cases to provide surgical proficiency during their training period

Freehand distal interlocking of intramedullary nails is technical demanding and prone to handling issues. It requires the surgeon to precisely place a screw through the nail under x-ray. If not performed accurately it can be a time consuming and radiation expensive procedure. The aims of this study were to assess construct and face validity of a new training device for distal interlocking of intramedullary nails. 53 participants (29 novices and 24 experts) were included. Construct validity was evaluated by comparing simulator metrics (number of x-rays, nail hole roundness, drill tip position and accuracy of the drilled hole) between experts and novices. Face validity was evaluated by means of a questionnaire concerning training potential and quality of simulated reality using a 7-point Likert scale (range 1-7). Mean realism of the training device was rated 6.3 (range 4-7) and mean training potential as well as need for distal interlocking training was rated 6.5 (range 5-7) with no significant differences between experts and novices, p≥0.236. All participants stated that the simulator is useful for procedural training of distal nail interlocking, 96% would like to have it at their institution and 98% would recommend it to their colleagues. Total number of x-rays were significantly higher for novices (20.9±6.4 vs. 15.5±5.3), p=0.003. Successful task completion (hit the virtual nail hole with the drill) was significantly higher in experts (p=0.04; novices hit: n=12; 44,4%; experts hit: n=19; 83%). The evaluated training device for distal interlocking of intramedullary nails yielded high scores in terms of training capability and realism. Furthermore, construct validity was established as it reliably discriminates between experts and novices. Participants see a high further training potential as the system may be easily adapted to other surgical task requiring screw or pin position with the help of x-rays

Aims. Evidence exists of a consistent decline in the value and time that medical schools place upon their undergraduate orthopaedic placements. This limited exposure to trauma and orthopaedics (T&O) during medical school will be the only experience in the speciality for the majority of doctors. This review aims to provide an overview of undergraduate orthopaedic training in the UK. Methods. This review summarizes the relevant literature from the last 20 years in the UK. Articles were selected from database searches using MEDLINE, EMBASE, ERIC, Cochrane, and Web of Science. A total of 16 papers met the inclusion criteria. Results. The length of exposure to T&O is declining; the mean total placement duration of two to three weeks is significantly less than the four- to six-week minimum advised by most relevant sources. The main teaching methods described in the literature included didactic lectures, bedside teaching, and small group case-based discussions. Students preferred interactive, blended learning teaching styles over didactic methods. This improvement in satisfaction was reflected in improvements in student assessment scores. However, studies failed to assess competencies in clinical skills and examinations, which is consistent with the opinions of UK foundation year doctors, approximately 40% of whom report a “poor” understanding of orthopaedics. Furthermore, the majority of UK doctors are not exposed to orthopaedics at the postgraduate level, which only serves to amplify the disparity between junior and generalist knowledge, and the standards expected by senior colleagues and professional bodies. Conclusion. There is a deficit in undergraduate orthopaedic training within the UK which has only worsened in the last 20 years, leaving medical students and foundation doctors with a potentially significant lack of orthopaedic knowledge. Cite this article: Bone Jt Open 2022;3(7):549–556

Simulation use in training is rapidly becoming a mainstay educational tool seen to offer perceived benefits of a safe environment for repeated practice and learning from errors without jeopardising patient safety. However, there is currently little evidence addressing the trainees’ perspectives and attitudes of simulation training, particularly in comparison with trainers and the educational community. This study investigates orthopaedic trainees’ and trainers’ conceptions of learning from simulation-based training, exploring whether the orthopaedic community are ‘on the same page’, with respect to each other and the educational community. Qualitative research in the form of semi-structured interviews is used to identify commonalities and differences between trainee and trainer conceptions, based on respective experiences and expectations, and suggests ways of enhancing collaboration between stakeholders to achieve better alignment of conceptions. The research revealed that orthopaedic trainees and trainers conceive key themes in a similar manner: supporting the role of simulation in developing the ‘pre-trained novice’ as opposed to skill refinement or maintenance; attributing greater importance to non-technical rather than technical skills development using simulation; questioning the transferability to practice of learnt skills; and emphasising similar barriers to increased curriculum integration, including financing and scheduling. These conceptions are largely in contrast to those of the educational community, possibly due to differing conceptions of learning between the two communities, along with a lack of a common language in the discourse of simulation. There was some evidence of changing attitudes and positively emerging conceptions among the orthopaedic community, and capitalising on this by engaging trainers and trainees may help reconcile the differing conceptions and facilitate increasing simulation utilisation and curriculum integration. Developing a common language to make the educational more tangible to surgeons, bringing the educational closer to the surgical, may help maximise the educational benefit and shape the future of simulation use in surgical training

Abstract. Introduction. Challenges in surgical training have led to the exploration of technologies such as augmented reality (AR), which present novel approaches to teaching orthopaedic procedures to medical students. The aim of this double-blinded randomised-controlled trial was to compare the validity and training effect of AR to traditional teaching on medical students’ understanding of total knee arthroplasty (TKA). Methodology. Twenty medical students from 7 UK universities were randomised equally to either intervention or control groups. The control received a consultant-led teaching session and the intervention received training via Microsoft HoloLens, where surgeons were able to project virtual information over physical objects. Participants completed written knowledge and practical exams which were assessed by 2 orthopaedic consultants. Training superiority was established via 4 quantitative outcome measures: OSATS scores, a checklist of TKA-specific steps, procedural time, and written exam scores. Qualitative feedback was evaluated using a 5-point Likert scale. Results. AR training was superior in teaching basic technical proficiency and understanding of TKA, with the intervention group significantly outperforming the control group in 3 metrics [OSATS (38.6%, p=0.021), checklist (33%, p=0.011) and written exam (54.5%, p=0.001)]. Procedural time was equivalent between cohorts (p=0.082). AR was rated as significantly more enjoyable (p=0.044), realistic (p=0.003), easy to understand (p=0.040), and proficient in teaching (p=0.02). Conclusion. In this adequately powered, double-blinded randomised-controlled trial, AR training demonstrated substantially improved translational technical skills and knowledge needed to understand TKA over traditional learning in medical students. Additionally, the results showed face, content, and transfer validity for AR in surgical training

The COVID-19 pandemic has disrupted all segments of daily life, with the healthcare sector being at the forefront of this upheaval. Unprecedented efforts have been taken worldwide to curb this ongoing global catastrophe that has already resulted in many fatalities. One of the areas that has received little attention amid this turmoil is the disruption to trainee education, particularly in specialties that involve acquisition of procedural skills. Hand surgery in Singapore is a standalone combined programme that relies heavily on dedicated cross-hospital rotations, an extensive didactic curriculum and supervised hands-on training of increasing complexity. All aspects of this training programme have been affected because of the cancellation of elective surgical procedures, suspension of cross-hospital rotations, redeployment of residents, and an unsustainable duty roster. There is a real concern that trainees will not be able to meet their training requirements and suffer serious issues like burnout and depression. The long-term impact of suspending training indefinitely is a severe disruption of essential medical services. This article examines the impact of a global pandemic on trainee education in a demanding surgical speciality. We have outlined strategies to maintain trainee competencies based on the following considerations: 1) the safety and wellbeing of trainees is paramount; 2) resource utilization must be thoroughly rationalized; 3) technology and innovative learning methods must supplant traditional teaching methods; and 4) the changes implemented must be sustainable. We hope that these lessons will be valuable to other training programs struggling to deliver quality education to their trainees, even as we work together to battle this global catastrophe

Abstract. Source of Study: London, United Kingdom. This intervention study was conducted to assess two developing protocols for quadriceps and hamstring rehabilitation: Blood Flow Restriction (BFR) and Neuromuscular Electrical Stimulation Training (NMES). BFR involves the application of an external compression cuff to the proximal thigh. In NMES training a portable electrical stimulation unit is connected to the limb via 4 electrodes. In both training modalities, following device application, a standardised set of exercises were performed by all participants. BFR and NMES have been developed to assist with rehabilitation following lower limb trauma and surgery. They offer an alternative for individuals who are unable to tolerate the high mechanical stresses associated with traditional rehabilitation programmes. The use of BFR and NMES in this study was compared across a total of 20 participants. Following allocation into one of the training programmes, the individuals completed training programmes across a 4-week period. Post-intervention outcomes were assessed using Surface Electromyography (EMG) which recorded EMG amplitude values for the following muscles: Vastus Medialis, Vastus Lateralis, Rectus Femoris and Semitendinosus. Increased Semitendinosus muscle activation was observed post intervention in both BFR and NMES training groups. Statistically significant differences between the two groups was not identified. Larger scale randomised-controlled trials are recommended to further assess for possible treatment effects in these promising training modalities

Superior teamwork in the operating theatre is associated with improved technical performance and clinical outcomes. Yet modern rota patterns, workforce shortages, and increasing complexity of surgery, means that there is less familiarity between staff and the required choreography. Immersive Virtual Reality (iVR) can successfully train surgical staff individually, however iVR team training has yet to be investigated. We aimed to design a multiplayer iVR platform for anterior approach total hip arthroplasty (AA-THA) and assess if multiplayer iVR training was superior to single player training for acquisition of both technical and non-technical skills. An iVR platform with choreographed roles for the surgeon and scrub nurse was developed using Cognitive Task Analysis. Forty participants were randomised to individual or team iVR training. Individually- trained participants practiced alongside virtual avatar counterparts, whilst teams trained live in pairs. Both groups underwent five iVR training sessions over 6-weeks. Subsequently, they underwent a real-life assessment in which they performed AA-THA on a high-fidelity model with real equipment in a simulated theatre. Teams performed together and individually trained participants were randomly paired up. Videos were marked by two blinded assessors recording the NOTSS, NOTECHS II and SPLINTS scores - validated technical and non-technical scores assessing surgeon and scrub nurse skills. Secondary outcomes were procedure time and number of technical errors. Teams outperformed individually trained participants for non-technical skills in the real-world assessment (NOTSS 13.1 ± 1.5 vs 10.6 ± 1.6, p =0.002, NOTECHS-II score 51.7 ± 5.5 vs 42.3 ± 5.6, p=0.001 and SPLINTS 10 ± 1.2 vs 7.9 ± 1.6, p = 0.004). They completed the assessment 28.1% faster (27.2 minutes ± 5.5 vs 41.8 ±8.9, p<0.001), and made fewer than half the number of technical errors (10.4 ± 6.1 vs 22.6 ± 5.4, p<0.001). Multiplayer training leads to faster surgery with fewer technical errors and the development of superior non-technical skills for anterior approach total hip arthroplasty. The convention of surgeons and nurses training separately, but undertaking real complex surgery together, can be supplanted by team training, delivered through immersive virtual reality

Superior team performance in surgery leads to fewer technical errors, reduced mortality, and improved patient outcomes. Scrub nurses are a pivotal part of this team, however they have very little structured training, leading to high levels of stress, low confidence, inefficiency, and potential for harm. Immersive virtual reality (iVR) simulation has demonstrated excellent efficacy in training surgeons. We tested the efficacy of an iVR curriculum for training scrub nurses in performing their role in an anterior approach total hip arthroplasty (AA-THA). Sixty nursing students were included in this study and randomised in a 1:1 ratio to learning the scrub nurse role for an AA-THA using either conventional training or iVR. The training was derived through expert consensus with senior surgeons, scrub nurses and industry reps. Conventional training consisted of a 1-hour seminar and 2 hours of e-learning where participants were taught the equipment and sequence of steps. The iVR training involved 3 separate hour-long sessions where participants performed the scrub nurse role with an avatar surgeon in a virtual operation. The primary outcome was their performance in a physical world practical objective assessment with real equipment. Data were confirmed parametric using the Shapiro-Wilk test and means compared using the independent samples student's t-test. 53 participants successfully completed the study (26 iVR, 27 conventional) with a mean age of 31±9 years. There were no significant differences in baseline characteristics or baseline knowledge test scores between the two groups (p>0.05). The iVR group significantly outperformed the conventionally trained group in the real-world assessment, scoring 66.9±17.9% vs 41.3±16.7%, p<0.0001. iVR is an easily accessible, low cost training modality which could be integrated into scrub nursing curricula to address the current shortfall in training. Prolonged operating times are strongly associated with an increased risk of developing serious complications. By upskilling scrub nurses, operations may proceed more efficiently which in turn may improve patient safety

The Ontario Crippled Children's Centre has completed a two-year research project designed to develop effective strategies for training the preschool child to use a myoelectric prosthesis. Two programmes were developed: one home-based with the parent as primary trainer, and the other Centre-based with a therapist as trainer. Seventeen children were successfully trained and fitted with myoelectric prostheses. Both training programmes appear to be equally effective, proving that informed parents can assume responsibility for the training of their children. Economic implications are self-evident. The functional assessment of the children's skill with the myoelectric prosthesis is very encouraging so far. However, long-term studies are indicated for adequate assessment of the cost-effectiveness of early myoelectric fitting. As a result of this study, effective training methods can now be used in routine clinical service; a manual is available to provide guidelines

Aims. The primary aim of the survey was to map the current provision of simulation training within UK and Republic of Ireland (RoI) trauma and orthopaedic (T&O) specialist training programmes to inform future design of a simulation based-curriculum. The secondary aims were to characterize; the types of simulation offered to trainees by stage of training, the sources of funding for simulation, the barriers to providing simulation in training, and to measure current research activity assessing the educational impact of simulation. Methods. The development of the survey was a collaborative effort between the authors and the British Orthopaedic Association Simulation Group. The survey items were embedded in the Performance and Opportunity Dashboard, which annually audits quality in training across several domains on behalf of the Speciality Advisory Committee (SAC). The survey was sent via email to the 30 training programme directors in March 2019. Data were retrieved and analyzed at the Warwick Clinical Trials Unit, UK. Results. Overall, 28 of 30 programme directors completed the survey (93%). 82% of programmes had access to high-fidelity simulation facilities such as cadaveric laboratories. More than half (54%) had access to a non-technical skills simulation training. Less than half (43%) received centralized funding for simulation, a third relied on local funding such as the departmental budget, and there was a heavy reliance on industry sponsorship to partly or wholly fund simulation training (64%). Provision was higher in the mid-stages (ST3-5) compared to late-stages (ST6-8) of training, and was formally timetabled in 68% of prostgrammes. There was no assessment of the impact of simulation training using objective behavioural measures or real-world clinical outcomes. Conclusion. There is currently widespread, but variable, provision of simulation in T&O training in the UK and RoI, which is likely to expand further with the new curriculum. It is important that research activity into the impact of simulation training continues, to develop an evidence base to support investment in facilities and provision

Aims. Total hip arthroplasties (THAs) are performed by surgeons at various stages in training with varying levels of supervision, but we do not know if this is safe practice with comparable outcomes to consultant-performed THA. Our aim was to examine the association between surgeon grade, the senior supervision of trainees, and the risk of revision following THA. Methods. We performed an observational study using National Joint Registry (NJR) data. We included adult patients who underwent primary THA for osteoarthritis, recorded in the NJR between 2003 and 2016. Exposures were operating surgeon grade (consultant or trainee) and whether or not trainees were directly supervised by a scrubbed consultant. Outcomes were all-cause revision and the indication for revision up to ten years. We used methods of survival analysis, adjusted for patient, operation, and healthcare setting factors. Results. We included 603,474 THAs, of which 58,137 (9.6%) procedures were performed by a trainee. There was no association between surgeon grade and all-cause revision up to ten years (crude hazard ratio (HR) 1.00 (95% confidence interval (CI) 0.94 to 1.07); p = 0.966), a finding which persisted with adjusted analysis. Fully adjusted analysis demonstrated an association between trainees operating without scrubbed consultant supervision and an increased risk of all-cause revision (HR 1.10 (95% CI 1.00 to 1.21); p = 0.045). There was an association between trainee-performed THA and revision for instability (HR 1.14 (95% CI 1.01 to 1.30); p = 0.039). However, this was not observed in adjusted models, or when trainees were supervised by a scrubbed consultant. Conclusion. Within the current training system in England and Wales, appropriately supervised trainees achieve comparable THA survival to consultants. Trainees who are supervised by a scrubbed consultant achieve superior outcomes compared to trainees who are not supervised by a scrubbed consultant, particularly in terms of revision for instability. Cite this article: Bone Joint J 2022;104-B(3):341–351

We present an evaluation of basic surgical orthopaedic operative training in the last 15 years, using multiple trauma and elective training procedures in orthopaedics. Identifying the influence of competency training and EWTD on Basic Surgical Training. Whilst trying to identify the area’s the MMC should concentrate on to provide a competent trainng programme. We assessed clinical exposure using 45 Basic Surgical Trainee Logbooks, from posts in 1990 (n=6), 1995 (n=7), 2000 (n=10), and 2004–5 (n=22); and looked at numbers of carpel tunnel decompression, and emergency hip, wrist, and ankle surgeries conducted. As well as the number of external fixators trainees were exposed to. In the 2004–5 group we prospectively assessed competency and knowledge of fracture neck of femur surgery. From a peak in operative surgery in 1990 numbers have fallen. Today, BST’s participate in 165 emergency hip cases (mean 4.6 procedures per trainee), today, 4.8% (n=8) as primary surgeon. In 1990, and 2000 trainees were primary surgeon in 43.4% (n = 12/32) and 25.2% (n=33/131) respectively. Trainees are comfortable with closure of skin, subcutaneous and muscular layers but not access; 91% (n=20) required assistance in positioning, and reduction, and recognition of correct alignment. Only 9.1% (n=2) felt competent without senior supervision (mean Orthopaedic BST experience 15.3 months) in hip surgery; whilst none knew of an intra-operative technique to reduce young adult capsular hip fractures. With regards to wrist and ankle fixation the decline has been dramatic decline by 11.1 and 5.9 procedures per trainee. Whilst, the numbers of forearm manipulations peaked in 1990–1995; it has since dropped to less than 5 per trainee in 2005 from 15–16. In 2005, it was also seen that a in a 6 month period a trainee in a typical district general hospital would be lucky to see an external fixator applied (average 0.6 per trainee in 6 month period). The decline of elective surgery is shown in carpel tunnel decompressions attended. In 1990 9.8 (6–14) were conducted as a primary operator, in 2005, it was 0.5 (0–3). The greatest decline in procedures of 46.3% occurred between 2000, to 2005. A comparison of total operating showed 88.9 (n=79–125) procedures in 6 months were lost between 1990 and 2005; with a 58.6% loss in trauma. This study suggests deficiency in operative competence today due to reduced opportunities. Thus emphasis should be placed on rota’s being matched to operative exposure, as trainee case numbers have declined sharply particularly in the last 5 years. The MMC should therefore ensure that trainees in the ST1 to 3 years reach their competencies with adequate time in the operating theatre

Abstract. Introduction. Knee arthroscopy can be used for ligamentous repair, reconstruction and to reduce burden of infection. Understanding and feeling confident with knee arthroscopy is therefore a highly important skillset for the orthopaedic surgeon. However, with limited training or experience, furthered by reduced practical education due to COVID-19, this skill can be under-developed amongst trainee surgeons. Methods. At a single institution, ten junior doctors (FY1 to CT2), were recruited as a part of a five, two-hour session, training programme utilising the Simbionix® ARTHRO Mentor knee arthroscopy simulator, supplemented alongside educational guidance with a consultant orthopaedic knee surgeon. All students had minimal to no levels of prior arthroscopic experience. Exercises completed included maintaining steadiness, image centering and orientation, probe triangulation, arthroscopic knee examination, removal of loose bodies, and meniscectomy. Pre and post-experience questionnaires and quantitative repeat analysis on simulation exercises were undertaken to identify levels of improvement. Results. Comparing pre and post-experience questionnaires significant improvements in levels of confidence were noted in the following domains: naming arthroscopic instruments, port positioning and insertion, recognising normal anatomy arthroscopically, holding and using arthroscopic instruments and assisting in a live theatre setting (p<0.05). Significant improvements were noted in time taken to complete, distance covered in metres and roughness of instruments used on the simulated exercises on repeat performance (p<0.05). Conclusion. With only five sessions under senior guidance, using a simulator such as the ARTHRO Mentor, significant improvements in both levels of confidence and skill can be developed even among individuals with no prior experience

Introduction. Knee arthroscopy can be used for ligamentous repair, reconstruction and to reduce burden of infection. Understanding and feeling confident with knee arthroscopy is therefore a highly important skillset for the orthopaedic surgeon. However, with limited training or experience, furthered by reduced practical education due to COVID-19, this skill can be under-developed amongst trainee surgeons. Methods. At a single institution, ten junior doctors (FY1 to CT2), were recruited as a part of a five, two-hour session, training programme utilising the Simbionix® ARTHRO Mentor knee arthroscopy simulator, supplemented alongside educational guidance with a consultant orthopaedic knee surgeon. All students had minimal to no levels of prior arthroscopic experience. Exercises completed included maintaining steadiness, image centring and orientation, probe triangulation, arthroscopic knee examination, removal of loose bodies and meniscectomy. Pre and post experience questionnaires and quantitative repeat analysis on simulation exercises were undertaken to identify levels of improvement. Results. Comparing pre and post experience questionnaires significant improvements in levels of confidence were noted in the following domains: naming arthroscopic instruments, port positioning and insertion, recognising normal anatomy arthroscopically, holding and using arthroscopic instruments and assisting in a live theatre setting (p<0.05). Significant improvements were also noted in time taken to complete and distance covered in metres, of the simulated exercises on repeat performance (p<0.05). Conclusion. Overall, with only five sessions under senior guidance, using a simulator such as the ARTHRO Mentor, significant improvements in both levels of confidence and skill can be developed even among individuals with no prior experience

This qualitative study aims to explore and highlight the experiences of trainees in the Orthopaedic Surgical Education Training (SET) program in New Zealand, with a focus on identifying gender-specific biases which may impact professional development. Orthopaedic SET trainees in New Zealand were invited to complete a qualitative, semi-structured questionnaire exploring their experiences in the Orthopaedic SET program. A broad range of topics were covered, addressing culture, belonging, learning styles and role modelling. Recurrent themes were identified using inductive methods. Analysis of questionnaire responses identified several key themes for women in the Orthopaedic SET program, compared to their male counterparts, including (1) role incredulity, (2) confidence vs. competence, (3) adaptation, (4) interdisciplinary relationships and (5) role modelling. Female participants described experiencing gender bias or discrimination by both patients and interdisciplinary colleagues at a higher rate than their male counterparts. The majority of female participants described feeling as competent as their male counterparts at the same SET level, however, identified that they do not typically exhibit the same confidence in their surgical abilities. Whilst similar numbers of female and male participants described experiencing barriers to career progression, female participants described having to adapt both physically and socially to overcome additional gender-specific barriers. Positive influences on training experience included role modelling and supportive relationships amongst trainee groups. This study highlighted gender-specific biases experienced by trainees in the Orthopaedic SET program in New Zealand. Further investigation is warranted to determine how these experiences affect professional development, and how they may be addressed to foster increased gender equity in the surgical profession. This will likely require system-level interventions to create meaningful and sustainable culture change

Introduction and Aim. Quadriceps strength is crucial for physical function in patients with knee osteoarthritis (KOA). This study aimed to investigate the effect of combining blood flow restriction (BFR) with low-intensity training (LIT) on quadricep strength in patients with advanced KOA. Methods. Patients with advanced KOA were block randomized by gender into the control or BFR group. The control group received LIT with leg press (LP) and knee extension (KE) at 30% of 1-repetition maximum (1-RM), while the BFR group underwent the same training with 70% limb occlusion. Physical function and patient-reported outcomes were assessed up to 16 weeks. Results. A total of 42 patients were analyzed: 22 in the BFR group (9 males, 13 females) and 20 in the control group (8 males, 12 females). In the BFR group, males exhibited increased KE power from the 4th to the 16th week (p<0.05) and LP power from the 4th to the 12th week (p<0.05). Females in the BFR group showed increased KE power in the 4th and 12th weeks (p<0.05), and LP power increased from the 4th to the 16th week (p<0.05). Males also had improved TSS at the 12th week, while females had improved TSS from the 8th to the 16th week. In the control group, males did not experience an increase in quadricep power. Females, however, had increased KE power in the 4th, 12th, and 16th weeks (p<0.05), and LP power from the 4th to the 12th week (p<0.05). Females in the control group also had improved TSS at the 4th week. Patient-reported outcomes did not differ, and all patients tolerated the training without any dropouts or adverse events. Conclusion. Combining BFR with LIT significantly improved quadricep power and physical function in both genders of KOA patients without exacerbating symptoms

Surgical trainees are finding it increasingly more challenging to meet operative requirements and coupled with the effects of COVID-19, we face a future of insufficiently trained surgeons. As a result, virtual reality (VR) simulator training has become more prevalent and whilst more readily accepted in certain arthroscopic fields, its use in hip arthroscopy (HA) remains novel. This project aimed to validate VR high-fidelity HA simulation and assess its functional use in arthroscopic training. Seventy-two participants were recruited to perform two basic arthroscopic tasks on a VR HA simulator, testing hip anatomy, scope manipulation and triangulation skills. They were stratified into novice (39) and experienced (33) groups based on previous arthroscopy experience. Metric parameters recorded from the simulator were used to assess construct validity. Face validity was evaluated using a Likert-style questionnaire. All recordings were reviewed by 2 HA experts for blinded ASSET score assessment. Experienced participants were significantly faster in completing both tasks compared with novice participants (p<0.001). Experienced participants damaged the acetabular and femoral cartilage significantly less than novice participants (p=0.011) and were found to have significantly reduced path length of both camera and instrument across both tasks (p=0.001, p=0.007), demonstrating significantly greater movement economy. Total ASSET scores were significantly greater in experienced participants compared to novice participants (p=0.041) with excellent correlation between task time, cartilage damage, camera and instrument path length and corresponding ASSET score constituents. 62.5% of experienced participants reported a high degree of realism in all facets of external, technical and haptic experience with 94.4% advising further practice would improve their arthroscopic skills. There was a relative improvement of 43% in skill amongst all participants between task 1 and 2 (p<0.001). This is the largest study to date validating the use of simulation in HA training. These results confirm significant construct and face validity, excellent agreement between objective measures and ASSET scores, significant improvement in skill with continued use and recommend VR simulation to be a valuable asset in HA training for all grades

Abstract. Objectives. Non-technical skills including teamwork play a pivotal role in surgical outcomes. Virtual reality is effective at improving technical skills, however there is a paucity of evidence on team-based virtual reality (VR) training. This study aimed to assess if multiplayer virtual reality training was superior to solo training for acquisition of both technical and non-technical skills in learning the complex anterior approach total hip arthroplasty operation. Methods. 10 novice surgeons and 10 novice scrub nurses, were randomised to solo or team virtual reality training to perform anterior approach total hip arthroplasty. Solo participants trained with virtual avatar counterparts, whilst teams trained in pairs (surgeon and scrub nurse). Both groups underwent 5 VR training sessions over 6 weeks. Then, they underwent a real-life assessment in which they performed AA-THA on a high-fidelity model with real equipment in a simulated operating theatre. Teams performed together and solo participants were randomly paired up with a solo player of the opposite role. Videos of the assessment were marked by two blinded expert assessors. Outcomes were procedure time, procedural errors from an expert pre-defined protocol and acetabular component positioning. Non-technical skills were assessed using the NOTECHs II and NOTSS scores. Results. Teams were 28.11% faster than solos in the real world assessment (31.22 minutes ±2.02 vs 43.43 ±2.71, p=0.01), with 34.91% less errors (−15.25 errors ±3.09 vs −23.43 ±1.84, p=0.04). Teams had significantly higher NOTSS and NOTECHS II scores when compared to solos (p<0.001). 8/10 surgeons placed the acetabular component within the target safe zone. Conclusions. Multiplayer training appears to lead to faster surgery with fewer technical errors and the development of superior non-technical skills. VR learnt skills appear to translate to the physical world. This supports the application of multidisciplinary learning to create a more integrated approach to surgical team training

Abstract. Objectives. Evidence supporting the use of immersive virtual reality (iVR) training in orthopaedic procedures is rapidly growing. However, the impact of the timing of delivery of this training is yet to be tested. This study investigated whether spaced iVR training is more effective than massed iVR training for novices learning hip arthroplasty. Methods. 24 medical students with no hip arthroplasty experience were randomised to learning total hip arthroplasty using the same iVR simulation training either once-weekly or once-daily for four sessions. Participants underwent a baseline physical world assessment to orientate an acetabular component on a saw bone pelvis, and a baseline knowledge test. In iVR, we recorded procedural errors, time, numbers of prompts required and path lengths of the hands and head across 4 sessions. To assess skill retention, the iVR and baseline physical world assessments were repeated at one-week and one-month. Results. Baseline characteristics between the groups were comparable (p > 0.05). The daily group demonstrated faster skills acquisition, reducing the mean number of procedural errors from 76.8±37.5 (S1) to 11.1±10.1 (S4), compared to the weekly group improvement from 71.1±19.1 (S1) to 17.2±10.6 (S4), p < 0.001. The weekly group error count plateaued remaining at 16±6.7 at 1-week and 17.5±8.5 at one-month, the daily group however, showed poor retention with error counts rising to 17.8±10.5 at 1 week and becoming higher than the weekly group at one-month to (23.2±13.0 vs 17.5±10.5). A similar effect was noted for procedural time and the number of assistive prompts. In the real-world assessment, both groups significantly improved the accuracy of their acetabular component positioning, these improvements were equally maintained. Conclusions. Daily iVR training facilitates faster skills acquisition, however weekly practice has superior skills retention. Skills learnt using both regimes demonstrate sustained transfer to the real-world

Orthopaedic training sessions, vital for surgeons to understand post-operative joint function, are primarily based on passive and subjective joint assessment. However, cadaveric knee simulators, commonly used in orthopaedic research,. 1. could potentially benefit surgical training by providing quantitative joint assessment for active functional motions. The integration of cadaveric simulators in orthopaedic training was explored with recipients of the European Knee Society Arthroplasty Travelling Fellowship visiting our institution in 2018 and 2019. The aim of the study was to introduce the fellows to the knee joint simulator to quantify the surgeon-specific impact of total knee arthroplasty (TKA) on the dynamic joint behaviour, thereby identifying potential correlations between surgical competence and post-operative biomechanical parameters. Eight fellows were assigned a fresh-frozen lower limb each to plan and perform posterior-stabilised TKA using MRI-based patient-specific instrumentation. Surgical competence was adjudged using the Objective Structured Assessment of Technical Skills (OSATS) adapted for TKA. 2. All fellows participated in the in vitro specimen testing on a validated knee simulator,. 3. which included motor tasks – passive flexion (0°-120°) and active squatting (35°-100°) – and varus-valgus laxity tests, in both the native and post-operative conditions. Tibiofemoral kinematics were recorded with an optical motion capture system and compared between native and post-operative conditions using a linear mixed model (p<0.05). The Pearson correlation test was used to assess the relationship between the OSATS scores for each surgeon and post-operative joint kinematics of the corresponding specimen (p<0.05). OSATS scores ranged from 79.6% to 100% (mean=93.1, SD=7.7). A negative correlation was observed between surgical competence and change in post-operative tibial kinematics over the entire range of motion during passive flexion – OSATS score vs. change in tibial abduction (r=−0.87; p=0.003), OSATS score vs. change in tibial rotation (r=−0.76; p=0.02). When compared to the native condition, post-operative tibial internal rotation was higher during passive flexion (p<0.05), but lower during squatting (p<0.033). Post-operative joint stiffness was greater in extension than in flexion, without any correlation with surgical competence. Although trained at different institutions, all fellows followed certain standard intraoperative guidelines during TKA, such as achieving neutral tibial abduction and avoiding internal tibial rotation,. 4. albeit at a static knee flexion angle. However, post-operative joint kinematics for dynamic motions revealed a strong correlation with surgical competence, i.e. kinematic variability over the range of passive flexion post-TKA was lower for more skilful surgeons. Moreover, actively loaded motions exhibited stark differences in post-operative kinematics as compared to those observed in passive motions. In vitro testing on the knee simulator also introduced the fellows to new quantitative parameters for post-operative joint assessment. In conclusion, the inclusion of cadaveric simulators replicating functional joint motions could help quantify training paradigms, thereby enhancing traditional orthopaedic training, as was also the unanimous opinion of all participating fellows in their positive feedback

Brazilian jiu-jitsu (BJJ) is a grappling-based martial art which can lead to injuries both in training and in competitions. There is a paucity of data regarding injuries sustained while training in Brazilian jiu-jitsu both in competitive and non-competitive jiu-jitsu athletes. Our primary objective was to determine the prevalence of injuries sustained during jiu-jitsu training and competition. Our secondary objectives were to describe the types of injuries, and to determine which participant and injury characteristics are associated with desire to discontinue jiu-jitsu following injury, and characteristics are associated with requiring surgery for an injury. We conducted a survey of all BJJ participants at one club in Hamilton Ontario. We developed a questionnaire using focus groups, key informants and the previous literature. The questionnaire included questions on demographics, injuries in competition and/or training, treatment received, and whether the participant considered discontinuing BJJ following injury. The primary analysis was descriptive. The secondary analysis consisted of unadjusted logistic regression analyses to evaluate the association between selected demographic and injury patterns and those who considered quitting jiu-jitsu as a result of their injuries as a dependent variable. Seventy BJJ athletes participated in this study (response rate 85%). The majority of respondents were male (90%), over the age of 30 years (58.6%), and junior trainees (white belts [37.2%] or blue belts [42.9%]). Ninety one percent of participants were injured in training and 60% of competitive athletes were injured in competitions. Significantly more injuries were sustained overall (p < 0 .001) for each body region (p∼0.001) in training in comparison to competition. Two-thirds of injured participants required medical attention, with 15% requiring surgery. Participants requiring surgical treatment were six and a half times more likely to consider quitting compared to those requiring other treatments, including no treatment (OR: 6.50, 95% CI: 1.53–27.60). Participants required to take more than four months off training were five and a half times more likely to consider quitting compared to those who took less time off (OR: 5.48, 95% CI: 2.25–13.38). We identified that nine out of ten jiu-jitsu practitioners surveyed suffered injury while in training and the most severe injuries for the majority of practitioners occurring during training. The most common injuries identified involved the fingers, neck, knee, and shoulder, with the majority of respondents seeking medical or surgical treatment or requiring physiotherapy or rehabilitation. Potential participants in BJJ should be informed regarding significant risk of injury and instructed regarding appropriate precautions and safety protocols. BJJ practitioners and instructors should be especially cognizant of safety during training, where the majority of injuries occur

Aims. The aim of this study is to determine the effects of the UK lockdown during the COVID-19 pandemic on the orthopaedic admissions, operations, training opportunities, and theatre efficiency in a large district general hospital. Methods. The number of patients referred to the orthopaedic team between 1 April 2020 and 30 April 2020 were collected. Other data collected included patient demographics, number of admissions, number and type of operations performed, and seniority of primary surgeon. Theatre time was collected consisting of anaesthetic time, surgical time, time to leave theatre, and turnaround time. Data were compared to the same period in 2019. Results. There was a significant increase in median age of admitted patients during lockdown (70.5 (interquartile range (IQR) 46.25 to 84) vs 57 (IQR 27 to 79.75); p = 0.017) with a 26% decrease in referrals from 303 to 224 patients and 37% decrease in admissions from 177 to 112 patients, with a significantly higher proportion of hip fracture admissions (33% (n = 37) vs 19% (n = 34); p = 0.011). Paediatric admissions decreased by 72% from 32 to nine patients making up 8% of admissions during lockdown compared to 18.1% the preceding year (p = 0.002) with 66.7% reduction in paediatric operations, from 18 to 6. There was a significant increase in median turnaround time (13 minutes (IQR 12 to 33) vs 60 minutes (IQR 41 to 71); p < 0.001) although there was no significant difference in the anaesthetic time or surgical time. There was a 38% (61 vs 38) decrease in trainee-led operations. Discussion. The lockdown resulted in large decreases in referrals and admissions. Despite this, hip fracture admissions were unaffected and should remain a priority for trauma service planning in future lockdowns. As plans to resume normal elective and trauma services begin, hospitals should focus on minimising theatre turnaround time to maximize theatre efficiency while prioritizing training opportunities. Clinical relevance. Lockdown has resulted in decreases in the trauma burden although hip fractures remain unaffected requiring priority. Theatre turnaround times and training opportunities are affected and should be optimised prior to the resumption of normal services. Cite this article: Bone Joint Open 2020;1-8:494–499

Introduction and Objective. Over the past few years, a reorganization of the educational pathways has been promoted with the purpose of optimizing the acquisition of competences and their assessment, so as to reduce the risks to both health care professionals and end users. Virtual reality (VR) has been repeatedly tested, initially as a positive reinforcement for more traditional educational pathways and, more recently, as their potential substitute. The aim of this study was to demonstrate the potentiality of VR simulation training in spine surgery. Materials and Methods. The VR simulator reproduced the lateral lumbar access to the spine. The simulation included a tutorial, the preoperative settings, and the surgical session with different levels of procedural complexity. A total of 10 users were recruited for this study: 3 senior surgeons (group A) and 7 orthopedic residents or junior orthopedic surgeons (group B). Each user completed the simulation twice. Results. The user's age or previous experience with VR technology did not show any relevance. On average, the entire simulation was completed in 24 minutes and 36 seconds. Group B showed an improvement between the 2 attempts in both sessions, the preoperative settings and the surgical simulation. The number of major errors dropped from an average of 5.2 to 1.8 and from an average of 4 (1–6) to 1.4, respectively. The simulation was never interrupted because of technical bugs or adverse effects related to the technology. Conclusions. VR-based training pathways might promote a high standard of care. Our preliminary experience suggests an effective implementation of the traditional coaching process

Aims. Rotator cuff muscle atrophy and fatty infiltration affect the clinical outcomes of rotator cuff tear patients. However, there is no effective treatment for fatty infiltration at this time. High-intensity interval training (HIIT) helps to activate beige adipose tissue. The goal of this study was to test the role of HIIT in improving muscle quality in a rotator cuff tear model via the β3 adrenergic receptor (β3AR). Methods. Three-month-old C57BL/6 J mice underwent a unilateral rotator cuff injury procedure. Mice were forced to run on a treadmill with the HIIT programme during the first to sixth weeks or seventh to 12th weeks after tendon tear surgery. To study the role of β3AR, SR59230A, a selective β3AR antagonist, was administered to mice ten minutes before each exercise through intraperitoneal injection. Supraspinatus muscle, interscapular brown fat, and inguinal subcutaneous white fat were harvested at the end of the 12th week after tendon tear and analyzed biomechanically, histologically, and biochemically. Results. Histological analysis of supraspinatus muscle showed that HIIT improved muscle atrophy, fatty infiltration, and contractile force compared to the no exercise group. In the HIIT groups, supraspinatus muscle, interscapular brown fat, and inguinal subcutaneous white fat showed increased expression of tyrosine hydroxylase and uncoupling protein 1, and upregulated the β3AR thermogenesis pathway. However, the effect of HIIT was not present in mice injected with SR59230A, suggesting that HIIT affected muscles via β3AR. Conclusion. HIIT improved supraspinatus muscle quality and function after rotator cuff tears by activating systemic sympathetic nerve fibre near adipocytes and β3AR. Cite this article: Bone Joint Res 2023;12(8):455–466

There is no unified national training system for orthopaedic surgeons in China. With such rapid progress in many aspects of life in China, there is an imminent need for improvement in the training of orthopaedic specialists. Since 2003 the orthopaedic community in Hong Kong has been working in collaboration with their colleagues in mainland China to develop a training system for orthopaedic surgery. We adopted the system from the Royal College of Surgeons of Edinburgh (RCSEd), setting up a trial centre in the Beijing Jishuitan hospital in 2006, with trainers and trainees attaining the standards set by RCSEd and the Hong Kong College of Orthopaedic Surgeons (HKCOS). This trial is ongoing, with the success of two trainees who passed the exit examination in 2010 and became the first Chinese orthopaedic surgeons with a joint fellowship of both the RCSEd and the HKCOS. Following this inaugural success, we are confident that China will develop a training system for orthopaedic surgeons to a consistently high international standard

The Postgraduate Medical Education and Training Board wants either ‘run through’ or ‘uncoupled’ orthopaedic training to be adopted throughout the United Kingdom but it is not willing to let both continue together as is the current situation. This annotation explores the argument for and against ‘run through’ training

In order to assess the efficacy of inspection and accreditation by the Specialist Advisory Committee for higher surgical training in orthopaedic surgery and trauma, seven training regions with 109 hospitals and 433 Specialist Registrars were studied over a period of two years. There were initial deficiencies in a mean of 14.8% of required standards (10.3% to 19.2%). This improved following completion of the inspection, with a mean residual deficiency in 8.9% (6.5% to 12.7%.) Overall, 84% of standards were checked, 68% of the units improved and training was withdrawn in 4%. Most units (97%) were deficient on initial assessment. Moderately good rectification was achieved but the process of follow-up and collection of data require improvement. There is an imbalance between the setting of standards and their implementation. Any major revision of the process of accreditation by the new Post-graduate Medical Education and Training Board should recognise the importance of assessment of training by direct inspection on site, of the relationship between service and training, and the advantage of defining mandatory and developmental standards

Background. Revision total knee arthroplasty (rTKA) is a high stakes procedure with complex equipment and multiple steps. For rTKA using the ATTUNE system revising femoral and tibial components with sleeves and stems, there are over 240 pieces of equipment that require correct assembly at the appropriate time. Due to changing teams, work rotas, and the infrequency of rTKR, scrub nurses may encounter these operations infrequently and often rely heavily on company representatives to guide them. In turn, this delays and interrupts surgical efficiency and can result in error. This study investigates the impact of a fully immersive virtual reality (VR) curriculum on training scrub nurses in technical skills and knowledge of performing a complex rTKA, to improve efficiency and reduce error. Method. Ten orthopaedic scrub nurses were recruited and trained in four VR sessions over a 4-week period. Each VR session involved a guided mode, where participants were taught the steps of rTKA surgery by the simulator in a simulated operating theatre. The latter 3 sessions involved a guided mode followed by an unguided VR assessment. Outcome measures in the unguided assessment were related to procedural sequence, duration of surgery and efficiency of movement. Transfer of skills was assessed during a pre-training and post-training assessment, where participants completed multi-step instrument selection and assembly using the real equipment. A pre and post-training questionnaire assessed the participants knowledge, confidence and anxiety. Results. All participants reported orthopaedics as their primary speciality with mean of 6-years experience. 80% reported they are ‘sometimes’ required to scrub for operations in which they do not feel comfortable with the equipment. All participants improved across the 3 unguided sessions reducing their operative time by 47%, assistive prompts by 75%, dominant hand motion by 28% and head motion by 36%. This transferred into the real-world: Participants completed 11.3% of tasks correctly in pre-training compared to 83.5% correct in the timely selection and assembly of rTKA equipment, post-training. All participants reported increased confidence and reduced anxiety after the training. Conclusion. Unfamiliarity with orthopaedic procedures or equipment is common for scrub nurses and can impact surgical performance. VR training improves their understanding, technical skills and efficiency in complex rTKA. These VR-learnt skills translate into the physical environment. This has important implications on how scrub nurses can be trained remotely, asynchronously and safely to perform complex orthopaedic surgery

There are significant differences in the methods and styles of orthopaedic surgical training between continents, all with the aim to produce competent consultant surgeons, but the differences in training content and pathway are vast. We review and contrast the key differences between three continents

Conventional fracture courses utilise prefabricated sawbones that are not realistic or patient specific. The aim of this study is to determine the feasibility of creating 3D fracture models and utilising them in fracture courses to teach surgical technique. We selected an AO type 2R3C2 fracture that underwent open reduction internal fixation. De-identified CT scan images were converted to a stereolithography (STL) format. This was then processed using Computer Aided Design (CAD) to create a virtual 3D model. The model was 3D printed using a combination of standard thermoplastic polymer (STP) and a porous filler to create a realistic cortical and cancellous bone. A case-based sawbone workshop was organised for residents, unaccredited registrars, and orthopaedic trainees comparing the fracture model with a prefabricated T-split distal radius fracture. Pre-operative images aided discussion of fixation, and post-operative x-rays allowed comparison between the participants fixation. Participants were provided with identical reduction tools. We created a questionnaire for participants to rate their satisfaction and experience using a Likert scale. The 3D printed fracture model aided understanding and appreciation of the fracture pattern and key fragments amongst residents and unaccredited trainees. Real case-based models provided a superior learning experience and environment to aid teaching. The generic sawbone provided easier drilling and inserting of screws. Preliminary results show that the cost of 3D printing can be comparable to generic sawbones. It is feasible to create a fracture model with a real bone feel. Further research and development is required to determine the optimum material to use for a more realistic feel. The use of 3D printed fracture models is feasible and provides an alternative to generic sawbone fracture models in providing surgical training to residents

Despite being one of the most common orthopaedic operations, it is still not known how many arthroscopies of the knee must be performed during training in order to develop the skills required to become a Consultant. A total of 54 subjects were divided into five groups according to clinical experience: Novices (n = 10), Junior trainees (n = 10), Registrars (n = 18), Fellows (n = 10) and Consultants (n = 6). After viewing an instructional presentation, each subject performed a simple diagnostic arthroscopy of the knee on a simulator with visualisation and probing of ten anatomical landmarks. Performance was assessed using a validated global rating scale (GRS). Comparisons were made against clinical experience measured by the number of arthroscopies which had been undertaken, and ROC curve analysis was used to determine the number of procedures needed to perform at the level of the Consultants. There were marked differences between the groups. There was significant improvement in performance with increasing experience (p < 0.05). . ROC curve analysis identified that approximately 170 procedures were required to achieve the level of skills of a Consultant. . We suggest that this approach to identify what represents the level of surgical skills of a Consultant should be used more widely so that standards of training are maintained through the development of an evidenced-based curriculum. Cite this article: Bone Joint J 2015;97-B:1309–15

Training time in Trauma & Orthopaedics is pressured. In this action research project, we develop a feedback/self-reflection model for trainers and trainees, emphasising the contribution both groups make to training, to maximise cohesion and efficacy. Starting in 2013, trainees completed anonymous feedback forms after each 6-month post. The 18-point quantitative questionnaire covers four training domains: WBA engagement, teaching/feedback, research/audit, operative training. Consultant trainers completed a once-off corresponding 18-point self-reflection questionnaire. Additionally, trainers were asked for their expectations of and advice for trainees. Individual trainer profiles were generated from trainee feedback questionnaires, allowing comparison between trainer-group-average, trainer-specific and trainer-self-reflection scores across 18 fields. Trainer profiles were uploaded to ISCP and used for recognition of trainer status for SOAR. This data provided basis for local service provision review with amendments to maximise training efficacy. Results of thematic analysis of trainer feedback was shared with the trainee group. This and subsequent group self-reflection formed the basis of our ‘Trainee Charter’. Trainee feedback illustrates high levels of satisfaction with local training (average global score 4.2/5). Strengths included ‘feedback’ and ‘operative teaching’; relative weaknesses included ‘research time’ and ‘OPD teaching’. The ‘Trainee Charter’ details specific desirable behaviours that embody eight trainee-qualities consistently identified by trainers as important, including ‘honesty’ and ‘being organised’. The charter emphasises trainee contribution to training. For the first time, trainers have the benefit of serial and individualised feedback. Trainees are better informed and empowered in relation to maximising their own training. Most importantly, both halves of the training-team are explicitly acknowledged

Background. For total hip arthroplasty (THA), cognitive training prior to performing real surgery may be an effective adjunct alongside simulation to shorten the learning curve. This study sought to create a cognitive training tool to perform direct anterior approach THA, validated by expert surgeons; and test its use as a training tool compared to conventional material. Methods. We employed a modified Delphi method with four expert surgeons from three international centres of excellence. Surgeons were independently observed performing THA before undergoing semi-structured cognitive task analysis (CTA) before completing successive rounds of electronic surveys until consensus. The agreed CTA was incorporated into a mobile and web-based platform. Forty surgical trainees (CT1-ST4) were randomised to CTA-training or a digital op-tech with surgical videos, before performing a simulated DAA THA in a validated fully-immersive virtual reality simulator. Results. Experts reached 100% consensus after five rounds. They defined THA in 46 steps and 52 decision points in 8 distinct procedural phases. Each phase comprised of a set of actions, cognitive demands, and critical errors and strategies. This CTA was mapped onto an open-access web-based learning tool [1]. Surgeons who prepared with CTA performed a simulated THA more efficiently (Time: 26 vs. 36 minutes and Procedural steps: 64 vs. 78), with fewer errors in instrument selection (22 vs 34 instances) and help required (6 vs. 19 instances), and with more accuracy (acetabular cup inclination error: 7° vs. 12°, anteversion error: 11° vs 19°) than those who prepared with conventional material. Discussion. This is the first validated CTA tool for arthroplasty. It provides structure for competency-based learning of this complex procedure. It is more effective at preparing orthopaedic trainees for a new procedure than conventional materials, for learning sequence, instrumentation and motor skills. Implications. Cognitive training combines education on decision making, knowledge and technical skill. It is a validated educational tool to upskill surgeons to perform hip arthroplasty and could replace current training and preparation methods for junior surgeons

Background. Virtual Reality (VR) uses headsets and motion-tracked controllers so surgeons can perform simulated total hip arthroplasty (THA) in a fully-immersive, interactive 3D operating theatre. The aim of this study was to investigate the effect of laboratory-based VR training on the ability of surgical trainees to perform direct anterior approach THA on cadavers. Methods. Eighteen surgical trainees (CT1-ST4) with no prior experience of direct anterior approach (DAA) THA completed an intensive 1-day course (lectures, dry-bone workshops and technique demonstrations). They were randomised to either a 5-week protocol of VR simulator training or conventional preparation (operation manuals and observation of real surgery). Trainees performed DAA-THA on cadaveric hips, assisted by a passive scrub nurse and surgical assistant. Performance was measured on the Intercollegiate Surgical Curriculum Project (ISCP) procedure-based assessment (PBA), on a 9-point global summary score (Table 1). This was independently assessed by 2 hip surgeons blinded to group allocation. The secondary outcome measure was error in cup orientation from a predefined target (40° inclination and 20° anteversion). Results. Surgeons trained using VR performed a cadaveric DAA-THA significantly better than those using conventional preparation, as assessed by acetabular cup orientation (p<0.001) and using the ISCP-PBA. Two VR surgeons achieved Level 3b, 6 were graded at Level 3a, and 1 was graded at Level 2b. Six non-VR surgeons achieved Level 2a and 3 were graded at Level 1b. Discussion. These data demonstrate transfer of procedural knowledge and psychomotor skills learnt from VR to a real-world setting. Conventional preparation had limited value for novice surgeons learning arthroplasty. VR training advanced them further up the learning curve. Implications. Virtual reality can augment surgical training for open procedures in orthopaedics curve, so opportunities in real surgery can be maximised. This has implications for how surgical training is delivered for surgeons learning a new, complex procedure. For any figures or tables, please contact the authors directly

Purpose of study. To evaluate implementation of the Back Skills Training (BeST) programme in clinical practice within the National Health Service (NHS). Background. The BeST programme is a group Cognitive Behavioural Approach (CBA) for people with persistent (≥6 weeks) low back pain (LBP). This intervention has been shown to be clinically and cost-effective in a large pragmatic trial. To aid implementation of the BeST programme, an online training intervention (iBeST) was developed. Methods. iBest was promoted through marketing activities (e.g. conferences, social media, evidence briefs) prior to release and launched in March 2016 for NHS health care professionals. Impact of iBeST is being evaluated by measuring number enrolled, course completion, implementation intention, clinical delivery, perceived competence, attitudes/beliefs towards LBP, knowledge and satisfaction. Data is collected at pre and post-training, 4 months and 12 months after course completion. A service evaluation is also being conducted to measure clinical impact. Patients taking part in the BeST programme as part of routine treatment complete questionnaires at baseline, post-treatment, 3 months and 12 months after the programme to assess pain, disability, recovery, satisfaction and usefulness of BeST. Results. 881 clinicians have enrolled on iBeST and 260 have completed training (target: 250). 28 NHS sites are delivering the BeST programme. 385 and 290 participants have provided baseline and post treatment data respectively (target: 400). Data collection is ongoing. Conclusion. Implementation is challenging but iBeST has been well received by NHS clinicians and we plan to report further results of the impact and service evaluation. Conflict of interest: None. Source of funding: This research is funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care Oxford at Oxford Health NHS Foundation Trust. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health

With the drawdown from Afghanistan focus turns towards future operations, and their demands on the DMS. Training for surgeons deploying to military operations will have to take into account the decreased opportunities and experience gained by current conflicts. The aim is to focus on current UK surgical training for military operations specifically. A comparison is made with US surgical training. A questionnaire was distributed to UK military surgical consultants in General Surgery, Trauma and Orthopaedics and Plastic Surgery. A similar questionnaire was sent to deployed US surgeons in SE Afghanistan. Response rates of 55% were achieved. Respondents were questioned on their confidence to perform several key procedures. Most UK consultants were satisfied with their overall training for deployment. Satisfaction rates were high for the MOST course and Danish Surgery. US satisfaction with pre-deployment training was poor. The majority of respondents felt confident to perform all haemorrhage and contamination control procedures in an emergency. However, most felt training for military personnel should be lengthened by a year or more to include greater exposure to other specialties. Whilst satisfaction with surgical training is high, many UK surgeons appear to suggest an increase in specialty exposure in preparation for future deployments

Drilling through bone is a complex action that requires precise motor skills of an orthopedic surgeon. In order to minimize plunging and soft tissue damage, the surgeon must halt drill progression precisely following penetration of the far cortex. The purpose of this study was to create a low-cost and easy-to-use drilling simulator to train orthopedic residents in reducing the drill plunging depth. This prospective observational study was performed in the division of orthopedic surgery of a single tertiary medical center. The participants included 13 residents and 7 orthopedic specialists. The simulator consisted of a synthetic femur bone model and ordinary modeling clay, and the training unit consisted of a disposable plastic tube (∼US$14), clamps (∼US$58) and a power drill + drill bit (standard hospital equipment). Plunging depths were measured by the simulator and compared between orthopedic specialists, the 6 “senior residents” (3+ years) and the 7 “junior residents” during a training session. Measurements were taken again 2 weeks following the training session. Initially, the plunging depths of the junior residents were significantly greater compared to those of the orthopedic specialists (7.00 mm vs 5.28 mm, respectively, p < 0.038). There was no similarly significant difference between the senior residents and the orthopedic experts ([6.33 mm vs. 5.28 mm, respectively; p = 0.18). The senior residents achieved plunging depths of 5.17 mm at the end of the training session and 4.7 mm 2 weeks later compared to 7.14 mm at the end of the training session and 6 mm 2 weeks later for the junior residents. This study demonstrated the capability of a low-cost drilling simulator as a training model for reducing the plunging depth during the drilling of bone and soft tissue among junior and senior residents

In June 2012 the Orthopaedic Speciality Advisory of the Joint Committee on Surgical Training defined ‘minimum indicative numbers’ that trainees would have to meet before completion of specialist training. It has been speculated that regions have varied in their ability to provide operative opportunities to their trainees. This study aims to test the hypothesis that there are regional differences in operative training experience. The eLogbook database was interrogated for cases over a 12 month period from 7 August 2013 to 5 August 2015. Within each region, the mean of the cases registered by orthopaedic trainees in each year of training during the study period was calculated and summed to give a representative surgical experience for the years ST3-8. First surgeon only cases were analysed for 11 index procedures in 30 T&O rotations. Considerable variation in training existed across rotations. In three index procedures, including DHS, no rotation achieved the minimum indicative number required. All rotations achieved the minimum indicative number of external fixator applications. This study proves the extent of the significant regional variation in surgical training in Trauma and Orthopaedics in the UK and raises concerns regarding the volume of operative training currently achieved

When compared to magnetic resonance imaging (MRI), ultrasound (US) performed by experienced users is an inexpensive tool that has good sensitivity and specificity for diagnosing rotator cuff (RC) tears. However, many practitioners are now utilizing in-office US with little to no formal training as an adjunct to clinical evaluation in the management of RC pathology. The purpose of our study was to determine if US without formal training is effective in managing patients with a suspected RC tear. This was a single centre prospective observational study. Five fellowship-trained surgeons each examined 50 participants referred for a suspected RC tear (n= 250). Patients were screened prior to the consultation and were included if ≥ 40 years old, had an MRI of their affected shoulder, had failed conservative treatment of at least 6 months, and had ongoing pain and disability. Patients were excluded if they had glenohumeral instability, evidence of major joint trauma, or osteonecrosis. After routine clinical exam, surgeons recorded their treatment plan (“No Surgery”, “Uncertain”, or “Surgery”). Surgeons then performed an in-office diagnostic US followed by an MRI and documented their treatment plan after each imaging study. Interrater reliability was analyzed using a kappa statistic to compare clinical to ultrasound findings and ultrasound findings to MRI, normal and abnormal categorization of biceps, supraspinatus, and subscapularis. Following clinical assessment, the treatment plan was recorded as “No Surgery” in 90 (36%), “Uncertain” in 96 (39%) of cases, “Surgery” in 61 (25%) cases, and incomplete in 3 (2%). In-office US allowed resolution of 68 (71%) of uncertain cases with 227 (88%) of patients having a definitive treatment plan. No patients in the “No Surgery” group had a change in treatment plan. After MRI, 16 (6%) patients in the “No Surgery” crossed-over to the “Surgery” group after identification of full-thickness tears, larger than expected tears or alternate pathology (e.g., labral tear). The combination of clinical examination and in-office US may be an effective method in the initial management of patients with suspected rotator cuff pathology. Using this method, a definitive diagnosis and treatment plan was established in 88% of patients with the remaining 12% requiring an MRI. A small percentage (6%) of patients with larger than expected full-thickness rotator cuff tears and/or alternate glenohumeral pathology (e.g., labral tear) would be missed at initial evaluation

Derriford Hospital gained Major Trauma Centre (MTC) status in April 2012, this led to a significant increase in the trauma case load. Our aim was to review registrar exposure to theatre and clinic in the elective and trauma setting. This was then compared to audits performed pre-MTC status and shortly following MTC changes to see if training standards were being maintained. Improvements in registrar rota planning were made following the previous assessment of training. Training was assessed with respect to national recommendations for registrar training. Data was collected for 8 weeks in February and March 2014 for all 12 registrars, and cross-referenced with the on-call and daily rota. The data was divided into training and non -training registrars. Elective exposure had improved in both theatres and clinic along with trauma theatre exposure whilst fracture clinic exposure had reduced since the previous audit. The reduction may be a result of the on-call registrar no longer being present in fracture clinic when on-call in compliance with MTC guidance. Rota management requires a fine balance between service and training commitments. Recent improvements to the management of the registrar rota appear to provide satisfactory training despite the pressures of MTC changes at Derriford Hospital

Total hip replacements (THRs) are performed by surgeons at various stages in their training, with varying levels of senior supervision. There is a balance between protecting training opportunities for the next generation of surgeons, while limiting the exposure of patients to unnecessary risk during the training process. The aim of this study was to examine the association between surgeon grade, the senior supervision of trainees, and the risk of revision following THR. We included 603 474 primary THRs recorded in the National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man (NJR) between 2003 and 2016 for an indication of osteoarthritis. Exposures were the grade of the surgeon (consultant or trainee), and whether trainees were supervised by a scrubbed consultant or not. Outcomes were all-cause revision, the indication for revision, and the temporal variation in risk of revision (all up to 10 years). Net failure was calculated using Kaplan-Meier analysis and adjusted analyses used Cox regression and flexible parametric survival analysis (adjusted for patient, operative, and unit level factors). There was no association between surgeon grade and all-cause revision up to 10 years (crude hazard ratio (HR) 0·999, 95% confidence interval (CI) 0.936–1.065; p=0.966); a finding which persisted with adjusted analysis. Adjusted analysis demonstrated an association between trainees operating without supervision by a scrubbed consultant and an increase in all-cause revision (HR 1.100, 95% CI 1.002–1.207; p=0.045). There was an association between the trainee-performed THRs and revision due to instability (crude HR 1.143, 95% CI, 1.007–1.298; p=0.039). However, this was not observed in fully adjusted models, or when trainees were supervised by a scrubbed consultant. Within the current training system in the United Kingdom, trainees achieve comparable outcomes to consultant surgeons when supervised by a scrubbed consultant. Revision rates are higher when trainees are not supervised by a scrubbed consultant but remain within internationally recognised acceptable limits

Surgical training has been greatly affected by the challenges of reduced training opportunities, shortened working hours, and financial pressures. There is an increased need for the use of training system in developing psychomotor skills of the surgical trainee for fracture fixation. The training system was developed to simulate dynamic hip screw fixation. 12 orthopaedic senior house officers performed dynamic hip screw fixation before and after the training on training system. The results were assessed based on the scoring system that included the amount of time taken, accuracy of guide wire placement and the number of exposures requested to complete the procedure. The result shows a significant improvement in amount of time taken, accuracy of fixation and the number of exposures after the training on simulator system. This was statistically significant using paired student t-test (p-value <0.05). Computer navigated training system appears to be a good training tool for young orthopaedic trainees The system has the potential to be used in various other orthopaedic procedures for learning of technical skills aimed at ensuring a smooth escalation in task complexity leading to the better performance of procedures in the operating theatre

Background. Accurate implant orientation is associated with improved outcomes after artificial joint replacement. We investigated if a novel augmented-reality (AR) platform (with live feedback) could train novice surgeons to orientate an acetabular implant as effectively as conventional training (CT). Methods. Twenty-four novice surgeons (pre-registration level medical students) voluntarily participated in this trial. Baseline demographics, data on exposure to hip arthroplasty, and baseline performance in orientating an acetabular implant to six patient-specific values on a phantom pelvis, were collected prior to training. Participants were randomised to a training session either using a novel AR headset platform or receiving one-on-one tuition from a hip surgeon (CT). After training, they were asked to perform the six orientation tasks again. The solid-angle error in degrees between the planned and achieved orientations was measured using a head-mounted navigation system. Results. Novice surgeons in both groups performed with a similar degree of error prior to training (AR: 14.2°±7.0°, CT: 15.7°±6.9° (p>0.05)). After training, average error was 10.7°±5.8° for AR participant and 7.2°±4.4° for CT participants. The average improvement per student was 3.5°±7.2° and 8.5°±8.0° respectively (p>0.05). Conclusions. A novel AR platform delivered training for acquiring skills to orientate an acetabular cup implant. After one session, novices trained by a hip surgeon outperformed those trained using AR. In both groups, accuracy remained below “expert” level proficiency (<5 degrees error). Further investigation is required to evaluate if novices retain skills, continue to improve with further training, and can transfer this to clinical practice

Purpose. Surgical training is based on an apprenticeship model. This training can be divided broadly into three main categories: practical skills, knowledge and decision making. The operating room is the nexus of a large part of surgical teaching. The supervising surgeon imparts both practical teaching as well as didactic information to the trainee during surgical procedures. A large amount of decision making skills are also acquired in the OR. Indeed, a large part of the surgical teams time is spent in the operating room which makes it an ideal educational environment. Bench model training is one teaching modality whereby the novice surgeon is taught surgical skills on life-like models. This practice enhances and accelerates the ability of the trainee to acquire fundamental, technical and surgical skills in the operating room. Whether bench model training provides an advantage on the ability of the trainee to acquire knowledge and decision making skills is unknown. Based on the motor learning theories, it is hypothesized that bench-model training will allow junior residents to be more interactive than trainees lacking similar active hands-on training. In this study, we examined whether bench model training provides an advantage on the ability of the trainee to acquire knowledge and decision making skills. Method. 30 junior surgical residents from various surgical divisions, with minimal knowledge of technical, procedural and cognitive skills related to the ulna bone fixation (primary task), were recruited in this study. 15 residents, randomly assigned, were given instructions and the benefit of practice on a bench model, and 15 were given instructions but not the chance to practice the skill on a bench model. All residents, while tested for their accuracy and time taken for ulna fixation (secondary task, decision making skills), were also verbally taught information on different aspects of primary bone healing. This information was evaluated by a multiple-choice test (knowledge acquisition). Results. Residents who practiced outperformed those without practice in ulna fixation in accuracy (P<0.05) and total time (p=0.0409, n=30). The group that were given bench model training also scored higher (P<0.05) on the multiple choice questions than the group that did not have the benefit of bench model training prior to testing. This showed that the trained group of residents had better ability for knowledge acquisition while performing the procedure than the untrained group. Conclusion. Bench model training can provide a means of enhancing learning, both in decision making skills and knowledge acquisition, in addition to motor learning activities inside the operating room

This paper discussed the challenges to provide advanced surgical training in orthopaedics, the inter-relationship between trainers, trainees, the AOA and the College. It looks at the factors that are involved in each level of training, some of the new initiatives that are being undertaken and the medicolegal issues regarding training of the modern generation of Orthopaedic trainees. It also discusses the pitfalls in process, that are present for all those involved in the training

Skills simulation is increasingly used as a training tool in postgraduate surgical training. Trainee's perception of the value of this experience has not previously been investigated. Our aim was to investigate the value of surgical simulation training delivered by an arthroscopy skills course. We constructed a subject-specific, self-assessment questionnaire based around the ISCP Peer Assessment Tool. The questionnaire was administered to candidates before and after attending the Plymouth Arthroscopy Skills Course. Participant demographic data was recorded. Questionnaire data was interrogated to give an overview of the course, as well as the benefit of site-specific skills stations. Statistical analysis showed the data to be normally distributed. The paired T-test was used to compare mean values. Twelve surgical trainees attended the course – CT2 trainees (n=4); ST3 trainees (n=7); ST4 trainee (n=1). 11 candidates completed both administered questionnaires giving a 92% response rate. The global mean score at the beginning of the course was 2.39. The global mean score at the end of the course was 3.90. The mean improvement was 1.51 (p<0.01; 95% CI = 0.96–2.07). Skill station specific scores all showed improvement with the greatest effect in wrist arthroscopy. CT trainees had a lower mean score compared to ST trainees. Both groups completed the course with similar mean scores. This study shows that arthroscopy simulation improves trainee-reported ratings of surgical skill. It also shows that less experienced candidates derived the greatest benefit from the training. Further research is required to compare self-assessed performance against objective benchmarks using validated assessment tools

Skills simulation is increasingly used as a training tool in postgraduate surgical training. Trainee's perception of the value of this experience has not previously been investigated. The aim of this investigation was to investigate the value of surgical simulation training delivered by an arthroscopy skills course. We constructed a subject-specific, self-assessment questionnaire based around the ISCP Peer Assessment Tool. The questionnaire was administered to candidates before and after attending the Plymouth Arthroscopy Skills Course. Participant demographic data was recorded. Questionnaire data was interrogated to give an overview of the course, as well as the benefit of site-specific skills stations. Statistical analysis showed the data to be normally distributed. The paired T-test was used to compare mean values. Twelve surgical trainees attended the course – CT2 trainees (n=4); ST3 trainees (n=7); ST4 trainee (n=1). 11 candidates completed both administered questionnaires giving a 92% response rate. The global mean score at the beginning of the course was 2.39. The global mean score at the end of the course was 3.90. The mean improvement was 1.51 (p<0.01; 95% CI= 0.96-2.07). Skill station specific scores all showed improvement with the greatest effect in wrist arthroscopy. CT trainees had a lower mean score compared to ST trainees. Both groups completed the course with similar mean scores. This study shows that arthroscopy simulation improves trainee-reported ratings of surgical skill. It also shows that less experienced candidates derived the greatest benefit from the training. Further research is required to compare self-assessed performance against objective benchmarks using validated assessment tools

Background. Complications such as dislocations, impingement and early wear following total hip arthroplasty (THA) increase with acetabular cup implant malorientation. These errors are more common with low-volume centres or in novice hands. Currently, this skill is most commonly taught during real surgery with an expert trainer, but simulated training may offer a safer and more accessible solution. This study investigated if a novel MicronTracker® enhanced Microsoft HoloLens® augmented reality (EAR) headset was as effective as one-on-one expert surgeon (ES) training for teaching novice surgeons hip cup orientation skill. Methods. Twenty-four medical students were randomly assigned to EAR or ES training groups. Participants used a modified sawbone/foam pelvis model for hip cup orientation simulation. A validated EAR headset measured the orientation of acetabular cup implants and displayed this in the participant”s field of view. The system calculated the difference between planned and achieved orientation as a solid-angle error. Six different inclination and anteversion combinations, related to hypothetical patient-specific anatomy, were used as target orientations. Learning curves were measured over four sessions, each one week apart. Error in orientations of non-taught angles and during a concealed pelvic tilt were measured to assess translation of skills. A post-test questionnaire was used for qualitative analysis of procedure understanding and participant experience. Results. Novice surgeons of similar experience in both groups performed with a similar error prior to training (ES: 15.7°±6.9°, EAR: 14.2°±7.1°, p>0.05). During training, EAR participants were guided to significantly better orientation errors than ES (ES: 6.0°±3.4°, EAR: 1.1°±0.9°, p<0.001). After four training sessions, the orientation error in both groups significantly reduced (ES: 15.7°±6.9° to 8.2°±4.6°, p<0.001; EAR: 14.2°±7.0° to 9.6°±5.7°, p<0.001). Participants in both groups achieved the same levels of orientation accuracy in non-taught angles and when the pelvis was tilted (p>0.05). In post-training evaluation, participants expressed a preference towards ES rather than EAR for learning orientation skills and related visuospatial and procedure-specific skills. 79% of participants indicated EAR simulator training and ES in combination would be their preferred training method. Discussion. A novel head-mounted EAR platform delivered training to novice surgeons more accurately than an expert surgeon. Both EAR and ES enabled novices to acquire and retain skills on a learning curve to orientate the implant. These skills were translated to non-taught orientations and in the presence of a pelvic tilt. Conclusions. Augmented-reality simulators may be a feasible and valid method for teaching novice surgeon”s visuospatial skills for THA on a learning curve, to compliment traditional intraoperative training

Introduction. Progressive resistance training (PRT) as a mean to reduce symptoms in patients with hip dysplasia (HD) has not yet been tried out. The aim of this study was to examine if PRT is feasible in patients with HD. A secondary purpose was to report data on changes of patient reported outcomes, muscle performance and hip muscle strength following PRT. Materials and methods. Patients diagnosed with HD on the waiting list for a periacetabular osteotomy (PAO) were offered to participate in a PRT feasibility study. The PRT intervention consisted of 8-weeks of supervised PRT consisting of 20 training sessions with exercises for the hips and knees. Feasibility was evaluated as adherence, the number of dropouts and adverse events. Furthermore, pain was reported after each exercise and one day after a training session using a 100mm visual analog scale (VAS). Pain was categorized as “safe” (VAS ≤20), “acceptable” (VAS >20–50) and “high risk” (VAS >50). Pre- and post the intervention patients completed the Copenhagen Hip and Groin Outcome Score (HAGOS), performed two hop-tests on each leg and had their peak torque of the hip extensors and flexors assessed by isokinetic dynamometry. Results. 16 patients, mean age 28 (range 22–40) years, completed the PRT intervention. Adherence was high (90.3% ±9.0%). Acceptable pain levels (VAS ≤50) were reported on average of 95% during the completed PRT sessions and after 92.3% of the sessions when assessed on the following day. Four out of six HAGOS subscales improved (P <0.05) after the intervention, as did standing distance jump and countermovement jump (8.3 cm 95% CI [1.2, 15.3], 1.8 cm [0.7, 2.9]) on the affected side. Dynamometry showed significant improved peak torque during isokinetic concentric hip flexion (15.8 Nm 95% CI [5.9, 25.8]) on the affected side. A similar improvement was seen during isometric hip flexion on the non-affected side. Conclusion. Supervised preoperative PRT is feasible in terms of drop outs, adherence, adverse events and pain levels in patients with HD scheduled for PAO. Furthermore, this feasibility study suggests that PRT may improve pain levels, patient reported outcomes, functional performance and hip flexion muscle strength

Aims: Musculo-skeletal complaints comprise a significant proportion of General Practitioner workload. The aim of this study was to assess whether the training of GP’s is satisfactory given their exposure to orthopaedics and trauma in practice. Methods: A postal questionnaire was sent to 200 local General Practitioners requesting information on their training in musculo-skeletal conditions. Results: The response rate was 58%. The reported estimated proportion of musculo-skeletal problems varied between 10% and 60 %. Only 33% of General Practitioners had any formal post graduate training in trauma and orthopaedics. Experience in the related specialities of rheumatology was 12% and A+E 69%. 35% of responding General Practitioners reported a specialist interest in musculo-skeletal conditions although less than 2% have any postgraduate qualifications in this area. Only 23% of GP’s thought that their training in orthopaedics and trauma was adequate .85% felt that they would benefit from further training. 80% of these felt that clinical teaching would be the best way to achieve this. Conclusions: Musculo-skeletal problems comprise a significant proportion of General Practice workload. Despite this fact formal training in trauma and orthopaedics received by GP’s is minimal. 77% of GP’s feel that their training in the treatment of musculo-skeletal conditions is inadequate and 85% would like further training

Background. The Fracture Fixation Assessment Tool score (FFATs) was developed as an objective evaluation of post-operative fracture fixation radiographs as a means of appraisal and education. The tool has proven validity, simple to use and based upon AO principles of fracture fixation. This study has been designed to assess how FFATs changes throughout the training program in the UK. Methods. The local trauma database of a district general hospital, with trauma unit status was used to identify cases. Although FFATs is designed to apply to any fracture fixation, Weber B ankle fractures were selected as common injuries, which constitute indicative cases in T&O training. Grade of the primary surgeon and supervision level were both stratified. The initial and intraoperative radiographs were anonymised and presented to the assessor who had been blinded to the identity and grade of the surgeon, for scoring using FFATs. Results. 293 fractures around the ankle were identified from the Database between 2013 and 2016. After applying the inclusion criteria of Weber B fractures operatively fixed, Specialist training registrars and consultants, there were 99 cases for evaluation. These were grouped by training experience into 4 groups. (ST3-4, ST5-6, ST7-8, Consultants) and demonstrated a trend of increasing scores with experience level with a dip in consultant scores, albeit not statistically significant due to low numbers of cases at higher training grades. Conclusions. We present our first experience of using FFATs in a uniform series of fractures in surgeons of different training grades. There is a trend to increasing scores throughout training with a dip in consultant scores likely reflecting increased complexity of cases. Implications. FFATs could prove to be an invaluable appraisal tool for teaching and mentoring surgeons in training both locally in the United Kingdom and remotely overseas

Introduction. The number of complex revision total hip arthroplasties (THA) is predicted to rise. The identification of acetabular bone defects prior to revision THA has important implications on technique and complexity of acetabular reconstruction. Paprosky et al. proposed a classification system including 3 main types with up to 3 subtypes focused on the integrity of the superior rim of the acetabulum and medial wall. However, the classification system is complex and its reliability has been questioned. The purpose of this study was to evaluate the effectiveness of different radiologic imaging modalities (plain radiographs, 2-D CT, 3-D CT reconstructions) in classifying acetabular defects in revision hip arthroplasty cases and their value of at different levels of orthopaedic training. Methods. Patients treated with revision total hip arthroplasty for acetabular bone defects between 2002–2012 were identified and 22 cases selected that had plain radiographs, 2-D CT and 3-D reconstructions available. Bone defects were classified independently by two fellowship-trained adult reconstruction surgeons. Representative sections were chosen and compiled into a timed presentation. Thirty-five residents from PGY-1 to PGY-5 and 4 attending orthopaedic surgeons were recruited for this study and received a 15-minute introduction to the classification system. Chi square analysis was utilized to examine the influence of image modality and level of training on the correct classification of acetabular bone loss using the Paprosky classification system with alpha=0.05. Results. The correct classification regardless of imaging of PGY levels was 30%. The level of training did not influence the ability to classify an acetabular defect (p=0.918). Correct classification was significantly influenced by the imaging used. Using x-ray led to 37% correctly identified defects, CT scans to 33% and 3D modeling to 30% of correct answers (p<0.001). For Class 1 defects, x-ray imaging had significantly higher number of correct classification (93%) compared to CT scans (67%) and 3D modeling (31%, p<0.001). Similarly, 2A defects were classified correctly with higher frequency on x-ray (49%) compared to CT scans (36%) or 3D modeling (15%, p=0.007). For type 2B, 2C, 3A and 3B defects, the type of imaging did not influence the frequency of correct answer. The level of training did not influence the frequency of correct classification regardless of the type of defect (p<0.05). However, there was a significant difference based on the defect type (p<0.001). Regardless of level of training or imaging, 64% of observers recognized type 1 defects, compared to only 16% correct recognition of 3B defects. Discussion. In the current study using different image modalities, residents regardless of the level of training were only able to classify 30% of defects correctly using the Paprosky classification system of acetabular defects. Using plain x-rays led to an increased number of correct classification, while regular CT scan and 3D CT reconstructions did not improve accuracy. The cost for advanced imaging when using this classification may not be justified. The Paprosky classification system of acetabular defects can be used for treatment decisions; however, it is complex and residents may require increased education in its use and identification of defects

The European Working Time Directive is a directive from the Council of Europe to protect the health and safety of workers in the European Union. The working time directive currently ensures a 56 working hour week and by August 2009 a 48 hour maximum working week. To accommodate such a reduction in working hours, the on call rotas for institutions have had to change. Has this had an affect on trauma exposure for current specialist registrars?. Materials and Methods: Data collection was from electronic logbooks of orthopaedic specialist registrars and locum appointment trainees on the Southwest Thames rotation. From the elogbooks indexed trauma procedures were audited, this included: dynamic hip screw, hemiarthroplasty, open reduction and internal fixation ankle, intramedullary nail femur, intramedullary nail tibia, and intramedullary nail humerus. The data was divided into year groups and then the data was subdivided into on call rotas. Obtained from the data collection was the number of indexed linked operations carried out per 6 months per year group. Results: The data collection was over an 18 month period October 2006 – April 2008. The total number of trainee logbooks who had the complete data from the logbook available was 90. The number of trainees for each year = n, the total number of operations =x and mean number of operations for each year of training =μ. The results for year groups are as follows:Year 1 n=18, x=4897, μ= 272:Year 2 n=12, x=2853, μ= 238: Year 3 n=22, x=4106, μ= 187:Year 4 n=19, x=3176, μ= 167:Year 5 n=4, x=658, μ=165:Year 6 n=15, x=3249, μ=217.Data for on call rotas were subdivided into the following groups: 1in13, 1in9, 1in8 and 1in7. The number of trainees for each on type of on call rota =n, the total number of operations = x, the mean number of operations for each on call rota group = μ.The results were as follows:1in13 on call: n=12, x=2215, μ=185; 1in9 on call: n=11, x=3195, μ=290. 1in8 on call: n=20, x=3754, μ=188; 1in7 on call: n=47, x=9775, μ=208. The results for the number of indexed linked operations carried out per 6 months per year group are as follows:YEAR 1 257.73:YEAR 2 228.24:YEAR 3 173.49: YEAR 4 173.23:YEAR 5 164.50: YEAR 6 208.49. Conclusion: The results show that year groups 1, 2 and 6 have carried out the highest number of procedures. The data also shows that trainees on the lowest frequency of on call rota call have the lowest number of indexed operations. The results for the number of indexed linked operations carried out per 6 months per year group shows that as the year groups progress the number of procedures carried out continues to decrease from year 1 to 5 and then increases again at year 6. The structure of orthopaedic training is being overhauled. The need for effective training has intensified. This audit aims to demonstrate some of the effects of the changes made in higher speciality training in orthopaedics

Aims. The aim of this study was to conduct evidence synthesis on the available published literature of the impact of the training status of the operating surgeon (trainee vs. consultant) on the survival and revision rate of primary hip and knee replacements. Patients and Methods. We conducted a systematic review according to Cochrane guidelines. Separate searches were performed for hip and knee replacements, with meta-analysis and presentation of results in parallel. We searched MEDLINE and Embase databases from inception to 17 September 2019 and included controlled trials and cohort studies reporting implant survival estimates, or revision rates of hip and knee replacements according to the grade of the operating surgeon. This study was registered with PROSPERO (CRD42019150494). Results. 8 studies (5 hip papers and 3 knee papers) met the inclusion criteria. There was no significant difference in the survival estimates for total hip replacements (THRs) performed by trainees compared to consultants at 5-years follow-up (97.9% vs 98.1%, p = 0.74). Furthermore, there was no significant difference in the revision rate of THRs performed by trainees and consultants at both 5 and 10-year intervals of follow-up (relative risk [RR]: 5yrs = 0.88 (95% CI: 0.46, 1.70; P = 0.71); 10yrs = 0.68 (95% CI: 0.37, 1.26; P = 0.22)). There was no significant difference in the survival estimates at 10-years for total knee replacements (TKRs) performed by trainees compared to consultants (96.2% vs 95.1%, p=0.49). Conclusion. There is no evidence in the existing literature that trainee surgeons have worse outcomes than their consultant colleagues, in terms of the survival, or rate of revision of hip and knee replacements at 5–10 years follow-up. This may mean that there is genuinely no difference or that, in the context of contemporary training programmes, appropriate case-mix selection and supervision of trainees is currently employed

The Royal Marines regularly deploy to Norway to conduct Cold Weather, Arctic and Mountain Warfare training. A total of 1200 personnel deployed to Norway in 2010 over a 14-week period. Patients, whose injuries prevented them from continuing training, were returned to the UK via AEROMED. The aim of this investigation was to describe the epidemiology of musculoskeletal injuries during cold weather training. All data on personnel returned to the UK was prospectively collected and basic epidemiology recorded. 53 patients (incidence 44/1,000 personnel) were returned to the UK via AEROMED. 20/53 (38%) of cases were musculoskeletal injuries (incidence 17/1000 personnel). 15/20 musculoskeletal injuries were sustained while conducting ski training (incidence 13/1,000): 4/20 were non-alcohol related injuries, 1/20 was related to alcohol consumption off duty. Injuries sustained whilst skiing: 5/15 sustained anterior shoulders dislocation, 5/15 Grade 1-3 MCL/LCL tears, 2/15 sustained ACJ injuries, 1/15 crush fracture T11/T12, 1/15 tibial plateau fracture and 1/15 significant ankle sprain. Non-Training injuries: 1 anterior shoulder dislocation, 1 distal radial fracture, 1 olecranon fracture, 1 Scaphoid Fracture and one 5th metatarsal fracture. 60% of injuries were upper limb injuries. The most common injury was anterior shoulder dislocation 6/20 (Incidence 5/1000). Our results suggest that cold weather warfare training has a high injury rate requiring evacuation: 4% of all people deployed will require AEROMED evacuation, and 2% have musculoskeletal injuries. Ski training causes the majority of injuries, possibly due to the rapid transition from non-skier to skiing with a bergen and weapon. Military Orthopaedic and rehabilitation units supporting the Royal Marines, should expect sudden increases in referrals when large scale cold weather warfare training is being conducted. Further research is required to see if musculoskeletal injury rates can be decreased in cold weather warfare training

The process of obtaining informed consent is an important and complex pursuit, especially within a paediatric setting. Medical governing bodies have stated that the role of the trainee surgeon must be explained to patients and their families during the consent process. Despite this, attitudes and practices of surgeons and their trainees regarding disclosure of the trainee's participation during the consent process has not been reported in the paediatric setting. Nineteen face-to-face interviews were conducted with surgical trainees and staff surgeons at a tertiary level paediatric hospital in Toronto, Canada. These were transcribed and subsequently thematically coded by three reviewers. Five main themes were identified from the interviews. 1) Surgeons do not consistently disclose the role of surgical trainees to parents. 2) Surgical trainees are purposefully vague in disclosing their role during the consent discussion without being misleading. 3) Surgeons and surgical trainees believe parents do not fully understand the specific role of surgical trainees. 4) Graduated responsibility is an important aspect of training surgeons. 5) Surgeons feel a responsibility towards both their patients and their trainees. Surgeons don't explicitly inform patients about the involvement of trainees, believing there is a lack of understanding of the training process. Trainee perspectives reflect this, with the view that families are aware of their participation but likely underestimate their role, and suggest that information is kept purposely vague to reduce anxiety. The majority of surgeons and surgical trainees do not voluntarily disclose the degree of trainee participation in surgery during the informed consent discussion with parents. An open and honest discussion should occur, allowing for parents to make an informed decision regarding their child's care. Further patient education regarding trainees' roles would help develop a more thorough and patient centred informed consent process

Utilising the (ACS-NSQIP) database, we aimed to evaluate the impact of resident level of training on surgical outcome following (TKA) and to compare the US and Canadian health care training system in regards to 30 days postoperative complications and readmission rates. Using the (CPT) codes we selected from the 2011 and 2012 NSQIP database elective primary TKA with the resident surgeon involved. Of these, all cases with a primary diagnosis code of infection, fracture, mechanical complication, or malignancy and all cases with incomplete or incongruous demographic information were excluded. We also eliminated all the cases with the Attending not present. A total of 2513 cases were included in the study. The cases were stratified into three groups according to the postgraduate level of training {PGY 1 to 3 (junior resident), PGY 4 to 5 (senior resident), and fellow}. Univariate analysis of all patient demographics, comorbidities, intra and postoperative variables, length of surgery, hospital stay and 30 days readmission rates were conducted in order to identify differences between the groups. A standard student's t test was used for continuous variables while the ChiSquared was used for categorical variables. Multivariable logistic regression models were created to assess the independent effect of the resident level of training on the 30 days major complication and re-admission rates while controlling for all other variables. We identified, 854 (34%) TKAs with junior residents, 1013 (40%) TKAs with senior residents and 646 (26%) TKAs with fellows' participation. Junior residents had a significant (p<0.0001) longer operative time (107±36 minutes) compared with senior residents and fellows. Length of hospital stay was longer in the fellow group probably because of their involvement in more complicated cases. Additionally, an increased number of blood transfusion was observed for the cases performed with involvement of senior residents when compared with the other two groups. However, no significant difference in complications was observed across training levels. When comparing US (2074 TKAs) versus Canada (423 TKAs) cases, we found that fellow contribution to TKA surgeries is higher in Canada. The occurrence of pulmonary embolism and pneumonia was three times higher in Canada cases, while blood transfusion was more frequent in US. Increased operative time, ASA class, age, diabetes, percutaneous cardiac intervention, and steroid use were all independent risk factors for complications following primary TKA. However, no significant difference was observed between the two groups with regards to major complications suggesting no difference between Canadian and American training system in regards to post operative complication. Our results support previous study study indicating that involvement of residents did not affect the surgical outcome within 30 days when compared to cases with no resident involvement. Our study suggests that resident level does not independently increase the risk of short term complications and support continuing involvement of junior trainees in TKA

Aim: To investigate the training of civilian Orthopaedic Trainee’s in complex trauma management. Methods: A web-based survey of orthopaedic trainees utilising three scenarios for investigating complex trauma management. 225 responses obtained, achieving a < 0.05 error rate with 90% confidence. Results:. Pelvic packing in exanguinating pelvic trauma:. 2.2% fully confidentto manage such a case. A positive correlation exists between increasing training and confidence. 58.9% have never seen such a case. No correlation exists between time in training and exposure. 62.8% report training in this case inadequate. A positive correlation exists between time in training and perceived inadequacy of ability to manage such a case. Junctional traum with non-compressible groin haemorrhage:. 0.4% fully confident. A positive correlation exists between time in training and confidence. 73.0% have never seen such a case. 67.9% report training in this case inadequate. No correlation was found between time spent in training and perceived training adequacy. Blood product resuscitation in trauma:. 11.6% were fully confident. 18.8% have never seen such a case. No correlation exists between time in training and confidence or exposure. 45.0% report training as inadequate in this case. No correlation seen between time in training and perceived training adequacy. Conclusion: Current training provides limited opportunities for exposure to significant trauma. The quality of care afforded to service personnel and civilians in recent conflict is unsurpassed and it is essential that the lessons learnt by deployed surgeons form a continuum to their successors. For military orthopaedic trainees this reinforces the need for closely supervised secondments on deployment; attendance at established military surgical training courses and appropriate fellowships to maximise exposure prior to first consultant deployment

Introduction and Aims: Stability training on a wobble board is a common method of rehabilitation from lower limb injuries. Injury prevention represents a relatively new application of this exercise but the neural mechanisms underlying its success remain unknown. We hypothesised that a three-week period of wobble board training will result in a decrease in the reflex response in the muscles crossing the left ankle joint. Method: Fourteen moderately trained university students were randomly assigned to a control and training group. The training group underwent 10-, 20-minute sessions of wobble board training over three weeks. Pre- and post-testing was conducted on an ankle perturbation rig and involved applying various levels of plantar torque to a stable (1DOF) and unstable (3 DOF) footplate. Nine potentiometers measured the position of the footplate, a force transducer measured the applied torque and a dorsiflexing perturbation could be given. Electromyographic data was recorded from four superficial muscles crossing the ankle joint to determine stretch reflex profiles for each muscle. Data was displayed in bar graphs and a two-way ANOVA was used. Results: No significant difference in the stretch reflex amplitude was noted between the training and control groups in medial gastrocnemius, lateral gastrocnemius, soleus or peroneus longus. A reduction in the amplitude of the stretch reflex in the experimental group was recorded after wobble board training in medial gastrocnemius (35% reduction), lateral gastrocnemius (25% reduction), soleus (15% reduction), and peroneus longus (40% reduction) during post-testing (significant at p < 0.05). There was no significant change in the amplitude of the stretch reflex in any of the four superficial muscles of the ankle joint in the control group between pre- and post-testing sessions. Conclusion: Presynaptic inhibition represents the most likely neural mechanism responsible for the observed reduction in the stretch reflex amplitude after a brief period of wobble board training. This neuromuscular adaptation may offer dynamic protection prior to and during heel contact, helping to prevent inversion sprains

Introduction: Surgical training is being greatly affected by the challenges of reduced training opportunities, shortened working hours, and financial pressures. There is thus an increased need for training systems to aid development of psychomotor skills of the surgical trainee. Furthermore, simulation environments can provide a friendlier and less hazardous environment for learning surgical skills. Such simulations may be used to augment training in the operating room (OR) so that trainees acquire key skills in a non-threatening and unhurried environment. Trajectory planning and implementation forms a substantial part of current and future orthopaedic practice. This type of surgery is governed by a basic orthopaedic principle where the placement of a surgical tool at a specific site within a region via a trajectory that is planned from X-ray based 2D images and is governed by 3D anatomical constraints. The accuracy and safety of procedures utilising the basic orthopaedic principle depends on the surgeon’s judgement, experience, ability to integrate images, utilisation of intra-operative X-ray, knowledge of anatomical-biomechanical constraints and eye hand dexterity. With the decrease in training opportunities in OR for the surgical trainee, these skills are developing at a much later stage in training. Several studies have shown a reduction in the number of operations undertaken and a reduction in the level of competence achieved by surgical trainees. Purpose of the study: This study develops our existing surgical CAOSS (Computer Assisted Orthopaedic Surgical System) [4, 5] for fracture fixation into a training tool for skill acquisition of the basic orthopaedic principle, namely, 3D navigation using 2D X-ray images. Material and Methods: Orthopaedic trainees who are presently working in Hull and East Yorkshire NHS Trust are recruited in this study. The study is divided into two parts. The initial part of the study involves the use of the conventional CAOSS to train the orthopaedic trainees with no prior exposure of distal locking of femoral nails and the dynamic hip screw. The second part of the study involves the use of modified CAOSS to assess whether the initial training has helped in developing mental navigation skills of using a 2-D image and navigating the drill bit in 3-D space. The scoring system is based on a combination of parameters which include the time taken for centring of the interlocking screw, total exposures taken and the improvement in the position of the tip of the drill bit with each exposure. Results: The presentation will discuss the theories, methodology and scoring criteria to produce a training tool for training of the basic orthopaedic principle and how the training tool was validated. Discussion: The ability to quantify precisely three-dimensional navigation and processing of virtual information to help in hand eye co-ordination has not previously been used as a formal orthopaedic training tool. Clearly the assessment of such skills demands a scoring system that is both reproducible as well as being able to validate it that it predicts skill acquisition correctly. Currently, there is no known scoring system which can accurately assess the ability to navigate instruments in 3-D space using a C-arm image. We therefore propose that using CAOSS as a training tool for the surgical trainees in a relaxing less hurried environment is beneficial to training and we also propose for this tool a reproducible scoring system

Parallel operating lists are a contentious subject. Many people feel that supervision, training and quality of patient care is negatively affected and consider this an outdated model in modern practice. Dual and parallel lists have been largely abandoned due to training committees' opinions that standards of orthopaedic training were being negatively affected. A new model of dual lists was implemented in a district general hospital as part of an arthroplasty service. The training impact was evaluated. Adjacent theatres were utilised for a single session. Two joint replacement surgeries were undertaken in each theatre. The sequential timing of the lists allowed the consultant to perform or supervise all of the operations in a consecutive manor. Staggering the start times allowed the consultant to approach and implant the first joint replacement, leaving the junior doctor or nurse practitioner to close the first operation and get the patient off the table while the consultant transferred to the adjoining theatre where the registrar had positioned, painted and draped the second patient, allowing the consultant to perform or supervise the second surgery. The process was then repeated until all four cases were performed. Evaluation of two registrar's elogbooks was undertaken and compared to the national average. During a twelve month period the trainees was involved in a mean of 72 joint replacement surgeries compared to a national average of 49. The trainees were the primary surgeon in a significantly higher number of operations compared to the national average. This model of sequential operating lists facilitated a service of high volume arthroplasty surgeries and significantly increased the exposure of the training registrar to joint replacements. Supervision of trainees was not significantly impacted. The model requires effective support services and a dedicated team of theatre staff, but can be very rewarding for consultant surgeon and trainee alike

Aims. The aim of this study was to assess the current evidence relating to the benefits of virtual reality (VR) simulation in orthopaedic surgical training, and to identify areas of future research. Materials and Methods. A literature search using the MEDLINE, Embase, and Google Scholar databases was performed. The results’ titles, abstracts, and references were examined for relevance. Results. A total of 31 articles published between 2004 and 2016 and relating to the objective validity and efficacy of specific virtual reality orthopaedic surgical simulators were identified. We found 18 studies demonstrating the construct validity of 16 different orthopaedic virtual reality simulators by comparing expert and novice performance. Eight studies have demonstrated skill acquisition on a simulator by showing improvements in performance with repeated use. A further five studies have demonstrated measurable improvements in operating theatre performance following a period of virtual reality simulator training. Conclusion. The demonstration of ‘real-world’ benefits from the use of VR simulation in knee and shoulder arthroscopy is promising. However, evidence supporting its utility in other forms of orthopaedic surgery is lacking. Further studies of validity and utility should be combined with robust analyses of the cost efficiency of validated simulators to justify the financial investment required for their use in orthopaedic training. Cite this article: Bone Joint J 2018;100-B:559–65

Background. The ability to learn arthroscopic surgery is an important aspect of modern day orthopaedic surgery. Knowing that variation in innate ability exists amongst medical students, the aim of this study was to investigate the effect of training on the arthroscopic surgical performance of our future orthopaedic surgeons (medical students). Methods. Two arthroscopic tasks (one shoulder and one knee) were set up in a bioskills laboratory to represent core skills required for arthroscopic training. Thirty three medical students with no previous arthroscopic surgery experience were randomised to a ‘Trained’ (n=16) and ‘Non-trained’ (n=17) cohort. Both groups watched an instructional video. The Trained cohort also received specific training on the tasks prior to their first episode. Thirty episodes of each task were then undertaken. The primary outcome variable was success or failure. Individuals were assessed as ‘competent’ if they stabilised their learning curve within 20 episodes. The secondary outcome measure was an objective assessment of technical dexterity using a validated Motion Analysis system (time taken to complete tasks, total path length of the subject's hands, and number of hand movements). Results. During the shoulder task, one subject in the Trained cohort failed to achieve competence compared with six subjects in the Non-trained cohort. During the knee task, two subjects in each cohort failed to achieve competence. Performance of the subjects in the Trained cohort during the shoulder task was significantly better (p<0.05, Chi-squared test). Based on the objective motion analysis parameters, the Trained cohort performed better than the Non-trained cohort for both tasks. This was statistically significant (p<0.05, Mann-Whitney U test) for the shoulder task. Conclusion. As expected, specific training can improve the arthroscopic performance of novices. There were, however, individuals who could not achieve competency in basic arthroscopic tasks even with focused training. Such assessments might influence students' future career choices

The aim of this study was to determine whether the foundation programme for junior doctors, implemented across the United Kingdom in 2005, provides adequate training in musculoskeletal medicine. We recruited 112 doctors on completion of their foundation programme and assessed them using the Freedman and Bernstein musculoskeletal examination tool. Only 8.9% passed the assessment. Those with exposure to orthopaedics, with a career interest in orthopaedics, and who felt that they had gained adequate exposure to musculoskeletal medicine obtained significantly higher scores. Those interested in general practice as a career obtained significantly lower scores. Only 15% had any exposure to orthopaedics during the foundation programme and only 13% felt they had adequate exposure to musculoskeletal medicine. The foundation programme currently provides inadequate training in musculoskeletal medicine. The quality and quantity of exposure to musculoskeletal medicine during the foundation programme must be improved

We investigated whether training doctors to classify proximal fractures of the humerus according to the Neer system could improve interobserver agreement. Fourteen doctors were randomised to two training sessions, or to no training, and asked to categorise 42 unselected pairs of plain radiographs of fractures of the proximal humerus according to the Neer system. The mean kappa difference between the training and control groups was 0.30 (95% CI 0.10 to 0.50, p = 0.006). In the training group the mean kappa value for interobserver variation improved from 0.27 (95% CI 0.24 to 0.31) to 0.62 (95% CI 0.57 to 0.67). The improvement was particularly notable for specialists in whom kappa increased from 0.30 (95% CI 0.23 to 0.37) to 0.79 (95% CI 0.70 to 0.88). These results suggest that formal training in the Neer system is a prerequisite for its use in clinical practice and research

Introduction and Objective. Hip osteoarthritis (OA) is the leading cause for total hip arthroplasty (THA). Although, being considered as the surgery of the century up to 23% of the patients report long-term pain and deficits in physical function and muscle strength may persist after THA. Progressive resistance training (PRT) appear to improve several outcomes moderately in patients with hip OA. Current treatment selection is based on low-level evidence as no randomised controlled trials have compared THA to non-surgical treatment. The primary objective of this trial is to determine the effectiveness of THA followed by standard care compared to 12 weeks of supervised PRT followed by 12 weeks of optional unsupervised PRT, on changes in hip pain and function, in patients with severe hip OA after 6 months. Materials and Methods. This is a protocol for a multicentre, parallel-group, assessor blinded, randomised controlled superiority trial. Patients aged ≥50 years with clinical and radiographic hip OA found eligible for THA by an orthopaedic surgeon will be randomised to THA or PRT (allocation 1:1). The primary outcome will be change in patient-reported hip pain and function, measured using the Oxford Hip Score. Key secondary outcomes will be change in the Hip disability and Osteoarthritis Outcome Score subscales, University of California Los Angeles Activity Score, 40-meter fast-paced walk test, 30-second chair stand test, and number of serious adverse events. Results. The trial has been approved by The Regional Committees on Health Research Ethics for Southern Denmark (Project-ID: S-20180158) in February 2019 and registration was performed at . ClinicalTrials.gov. (NCT04070027) in August 2019. Recruitment was initiated on the 2. nd. of September 2019 and the final deadline will be on the 30. th. of June 2021, or when a sample size of 120 patients has been accomplished. Conclusions. The results of the current trial are expected to enable evidence-based recommendations, which may be used to facilitate the shared-decision making process in the discussion of treatment strategy for the individual patient with severe hip OA. All results will be presented in peer-reviewed scientific journals and international conferences

Joint assessment through manual physical examination is a fundamental skill that must be acquired by orthopaedic surgeons. These joint assessments allow surgeons to identify soft tissue injuries (e.g. ligament tears) which are critical in identifying appropriate treatment options. The difficulty in communicating the feeling of different joint conditions and the limited opportunities for practice can make these skills challenging to learn, resulting in reduced treatment effectiveness and increased costs. This research seeks to improve the training of joint assessment with the creation of a haptic joint simulator that can train surgeons with increased effectiveness. A first of its kind haptic simulator is presented, which incorporates: a newly defined kinetic knee simulation, a haptic device for user interaction, and a haptic control algorithm. The knee model has been specifically created for this application and allows six degree-of-freedom manipulation of the tibia while considering the effects of ten knee ligament bundles. The model has been mathematically formulated to allow for the high update rates necessary for smooth and stable haptic simulation. Two quantitative assessments were made of the model to confirm its clinical validity. The first was against the widely used OpenSim biomechanical simulation software. Simulations of the model's performance for both anterior-posterior draw tests and varus-valgus rotation tests showed less than 0.7%RMSE for force and 5.5%RMSE for moments. Crucially, the proposed model could generate updated forces in less than 1ms, compared to 188ms for OpenSim. The second validation of the model was against a cadaveric knee that was tested using a validated robotic testing platform. This comparison showed that the model could generate similar force- motion pathways to the cadaveric knee after the model's parameters were scaled to match. Having demonstrated that it is possible to create a computational knee model that has good conformance to gold-standard knee simulations and cadaveric recordings, while updating at less than 1ms, this research has overcome a major hurdle. The next stage of this research will be to incorporate the knee model into a full haptic simulator and perform skill acquisition trials. Given the effectiveness of past haptic training systems in aiding clinical skills acquisition, this research offers a promising way to improve surgeon training, and therefore also patient diagnosis and treatment

Introduction: Complex extremity injury remains a challenge to those involved in both its emergent and definitive care. Anecdotal concerns exist regarding exposure of orthopaedic trainees to such cases in the light of recent changes in surgical training. We aim to establish the perceived confidence, exposure to caseload and adequacy of training of United Kingdom (UK) Orthopaedic Specialist Trainees in the management of significant extremity trauma. Method: A web-based survey was sent to a sample of orthopaedic trainees. 222 responses from 888 trainees were required to achieve a 5% error rate with 90% confidence. 232 responses were received. Results: Perceived confidence and adequacy of training in wound debridement and fasciotomy is high despite infrequent exposure and training is perceived as adequate. With regards to assessment of limb viability and amputation for extremity injury, exposure is minimal, perceived confidence is lower, particularly in the case of amputation and for this scenario over a third of trainees report their training as inadequate. Perceived confidence in dealing with hand trauma is low and is associated with sparse exposure to cases resulting in a quarter of trainees reporting their training as inadequate. For all scenarios, confidence is seen to increase with time spent in training with the notable exception of post-CCT trainees whom report a lower confidence to their colleagues in the latter years of training. Discussion: Despite infrequent exposure, it has been demonstrated that perceived confidence and adequacy of training in many aspects of extremity injury is high. Concerns are apparent with the management of hand trauma and amputation surgery. This study is the first of its kind to offer a valuable insight into the current training perceptions and requirements of junior orthopaedic surgeons at a national level

Computer assisted navigation (CAN) has been shown to significantly improve the overall alignment obtained after total knee arthroplasty (TKA). Human error and the use of conventional jigs may be the reasons for the inaccuracy of conventional TKA. The impact of computer assisted equipment in surgeon training has not yet been established. Three orthopaedic trainees participated in this prospective study to assess the impact of CAN upon intraoperative alignment. Each trainee’s first five (early group) and last five (late group) TKA’s were included in the study during their three month training period. A total of 30 patients were included in the study. The accuracy of conventional jig positioning was assessed simultaneously using navigation equipment. After this assessment, the actual bony resection was performed using CAN equipment. There was a consistent trend towards improved accuracy between the early and late groups in the majority of parameters assessed. In the early group, the coronal plane tibial alignment was found to be outside the acceptable three degree range in 11 out of 15. In the late group this improved to two out of 15 (p< 0.05). An average of 2.8 degrees of tibial jig deviation during pinning was noted in the early group which improved to one degree in late group. The accuracy of jig placement in both groups was improved by CAN. Computer assisted navigation is helpful in improving the accuracy of trainee surgeons and should prove a useful adjunct in training. Surgical accuracy using conventional jig based systems can be improved with training. Deviation of conventional tibial alignment jig during pinning is a significant factor. This aspect has not been appreciated fully in the past and can be minimised by the use of the navigation equipment. As shown in previous studies, the overall alignment using CAN is superior to what would have been obtained using conventional jigs for TKA

Nationwide changes in the organisation of specialist medical training present a challenge to surgical trainees in terms of exposure to an adequate case load, the acquisition of practical experience and therefore also of judgement and decision-making. When accompanied by accredited trainers exposure to practice in the developing world offers trainees the opportunity to enhance their clinical exposure as well as skills in communication, teaching, management and leadership. This paper analyses the training value for orthopaedic trainees of a novel orthopaedic project undertaken in Kenya in February 2009 utilising an entire UK orthopaedic team. The first Kenya Orthopaedic Project (KOP) was organised by an orthopaedic trainee and took place at Nanyuki District General Hospital in February 2009. Kenya does not have the luxury of a national health service and patients must pay for any clinics or surgery. The cost of orthopaedic surgery in this environment is prohibitive and many fractures go untreated, as do other common pathologies such as severe osteoarthritis and osteomyelitis. The UK team undertaking the project included two accredited consultant orthopaedic surgeons and an orthopaedic trainee. Clinics, surgery and teaching sessions were performed for one week with the aim of relieving the sheer volume of orthopaedic cases and to provide those impoverished patients with treatment they would not otherwise receive. Data was taken from elogbook to analyse the average number of cases performed by an orthopaedic ST3 in one week, and a survey was sent to all Southwest trainees (n=25) for information on how many competencies and work placed based assessments were completed in one week. Daily challenges of health care budgeting, negotiating, organisational and intercultural communication skills are not often encountered by UK orthopaedic trainees, and bring with them a realisation of the wider picture of health care economics and appreciation of the benefits of a National Health Service. The results showed that in one week during KOP over seventy patients were seen in clinic and eighteen operations performed. Of the 18 operations performed the orthopaedic trainee assisted in 15 of these operations and performed 3 under supervision. An average week log book entry for ST3 trainees, taken from elogbook statistics, contains six elective and three trauma operations. The figures from one week Kenya Orthopaedic Project double these operative numbers. Six workplace based assessments were completed in one week on the project, significantly more than an average of 0.16 per week in UK. (p=0.0003). In conclusion Kenya Orthopaedic Projects offer a unique experience for orthopaedic trainees and all members of the multidisciplinary team. Trainees are offered the opportunity to put into practice managerial, teaching, organisational and communication skills as well as the chance to see and treat pathologies that would not be encountered in the UK. The experience of operating in third world conditions with minimal equipment available, communicating with patients and theatre staff from a different culture whilst ensuring all possible western world safety measures are adhered to offers a wholly challenging and valuable perspective to an orthopaedic trainee. Both operative experience and workplace based assessments statistically surpassed that of an average week of a UK trainee. We can therefore conclude that a week’s orthopaedic experience in a third world country is not only beneficial to the patients but offers excellent training opportunities in all aspects of the delivery of health care and makes a positive contribution to orthopaedic training

Summary Statement. Incorrect pedicle screw placement can lead to neurological complications. Practice outside the operating room on realistic bone models, with force feedback, could improve safety. Pedicle forces in cadaveric specimens are reported, to support development of a training tool for residents. Introduction. Inserting screws into the vertebral pedicles is a challenging step in spinal fusion and scoliosis surgeries. Errors in placement can lead to neurological complications and poor mechanical fixation. The more experienced the surgeon, the better the accuracy of the screw placement. A physical training system would provide orthopaedic residents with the feel of performing pedicle cannulation before operating on a patient. The proposed system consists of realistic bone models mimicking the geometry and material properties of typical patients, coupled with a force feedback probe. The purpose of the present study was to determine the forces encountered during pedicle probing to aid in the development of this training system. Methods. We performed two separate investigations. In the first study, 15 participants (9 expert surgeons, 3 fellows, 3 residents) were asked to press a standard pedicle awl three times onto a mechanical scale, blinded to the force, demonstrating what force they would apply during safe pedicle cannulation and during unsafe cortical breach. In the second study, three experienced surgeons used a standard pedicle awl fitted with a one-degree of freedom load cell to probe selected thoracolumbar vertebrae of eight cadaveric specimens to measure the forces required during pedicle cannulation and deliberate breaching, in randomised order. A total of 42 pedicles were tested. Results. Both studies had wide variations in the results, but were in general agreement. Cannulation (safe) forces averaged approximately 90 N (20 lb) whereas breach (unsafe) forces averaged approximately 135–155 N (30–35 lb). The lowest average forces in the cadaveric study were for pedicle cannulation, averaging 86 N (range, 23–125 N), which was significantly lower (p<0.001) than for anterior breach (135 N; range, 80–195 N); medial breach (149 N; range, 98–186 N) and lateral breach (157 N; range, 114–228 N). There were no significant differences among the breach forces (p>0.1). Cannulation forces were on average 59% of the breach forces (range, 19–84%) or conversely, breach forces were 70% higher than cannulation forces. Discussion. To our knowledge, axial force data have not previously been reported for pedicle cannulation and breaching. A large range of forces was measured, as is experienced clinically. Additional testing is planned with a six-degree-of-freedom load cell to determine all of the forces and moments involved in cannulation and breaching throughout the thoracolumbar spine. These results will inform the development of a realistic bone model as well as a breach prediction algorithm for a physical training system for spine surgery. The opportunity to learn and practice outside of the operating room, including learning from deliberate mistakes, should increase the confidence and comprehension of residents performing the procedure, enhance patient safety, reduce surgical time, and allow faster progression of learning inside the operating room

Aims

To identify a core outcome set of postoperative radiographic measurements to assess technical skill in ankle fracture open reduction internal fixation (ORIF), and to validate these against Van der Vleuten’s criteria for effective assessment.

Since 2003 Trauma and Orthopaedic trainees in the UK and Ireland have routinely submitted data recording their operative experience electronically via the eLog-book. This provides evidence of operative experience of individuals and national comparisons of trainee, trainer, hospital and training programme performance. We have analysed trauma surgery data and established standards for training. By January 2008 there were over 4 million operations logged. Operations performed and uploaded since 2003 have been included. Each trainee’s work is analysed by ‘year-in-training’. Data on levels of supervision, missed opportunities (where the trainee assisted rather than performed the operation) was analysed. The average number of trauma operations performed annually by trainees was 109, 120, 110, 122, 98 and 84 (total 643) for YIT one (=ST3) to six (=ST8) respectively. There were only 22% of missed opportunities throughout six years of training. A high level of experience is gained in hip fracture surgery (121 operations) and forearm (30), wrist (74) and ankle (47) operative stabilisation over the six years. However, the average number of tibial intra-medullary nails (13), external fixator applications (12) and childrens’ elbow supracondylar fracture procedures (4) performed is low. We are also able to identify trainees performing fewer operations than required during their training (two standard deviations or more below the mean for their YIT). We expect a trainee to have performed at least 255, 383, 473, and 531 trauma operations at the end of YIT three to six respectively. The eLogbook is a powerful tool which can provide accurate information to support in-depth analysis of trainees, trainers, and training programmes. This analysis has established a baseline which can be used to identify trainees who are falling below the required operative experience

Purpose: To evaluate fellowship trainee and supervisor perceptions on the relative importance of core cognitive and procedural competencies in spine subspecialty fellowship training. Method: A questionnaire was designed through synthesis and amalgamation of two previous surveys designed by other authors. This questionnaire was reviewed for content by spine surgery experts (Canadian Spine Society Education Committee). The questionnaire was administered (online and paper) to fellow trainees and supervisors across Canada and data was collected over a 3-month period. It consisted of 40 MCQ items grouped into 13 broad cognitive skills categories, as well as 29 technical/procedural items. Data was analyzed using qualitative and descriptive statistics (e.g. average mean scores, standard deviations, t-tests). Results: The response rate was 91%, with 15 of 17 fellow trainees and 47 of 51 supervisors completing the survey. Twelve of the 13 core cognitive skill categories were rated as being important to acquire by the end of fellowship. Trainees were not comfortable performing, and requested additional training in 8 of 29 spine surgery technical skill items. Specifically, additional training was believed to be required for intradural procedures (e.g. syringomyelia, intradural neoplasms) and other less common, technically demanding, procedures (e.g. transoral odontoidectomy, anterior thoracic discectomy). Significant differences (p< 0.05) existed in perceptions of importance for specific cognitive and technical skills based on previous residency training (orthopaedic or neurosurgical). No such differences were found when comparing responses of the fellow trainees and their supervisors. Conclusion: This study demonstrates that fellowship trainees and supervisors have similar perceptions on the relative importance of specific core cognitive and procedural competencies required in achieving successful spine fellowship training. Furthermore, background specialty training (orthopaedic or neurosurgical) influences the perceptions of both fellow trainees and supervisors regarding the importance of specific cognitive and technical skills deemed necessary for successful training

Introduction. Surgical simulation and ‘virtual’ surgical tools are becoming recognised as essential aids for speciality training in Trauma & Orthopaedics, as evidenced by the BOA T&O Simulation Curriculum 2013. 1,2. The current generation of hip arthroplasty simulators, including cadaveric workshops, offers the trainee limited exposure to reproducible real life bony pathology. We developed and implemented a novel training course using pathological dry bone models generated from real patient cases to support senior orthopaedic trainees and new consultants in developing knowledge and hands on skills in complex total hip arthroplasty. Patient/Materials & Methods. A two-day programme for 20 delegates was held at a specialist centre for hip arthroplasty. Three complex femoral and three complex acetabular cases were identified from patients seen at our centre. 3D models were printed from CT scans and dry bone models produced (using a mold-casting process), enabling each delegate to have a copy of each case at a cost of around £30 per case per delegate (Figure 1). The faculty was led by 4 senior Consultant revision hip surgeons. A computerised digitising arm was used to measure cup positioning and femoral stem version giving candidates immediate objective feedback (Figure 2). Candidate experience and satisfaction with the course and models was evaluated with a standardised post-course questionnaire. Results. 91% of respondents rated overall course satisfaction good or very good with 100% stating learning objectives were met or exceeded. 100% of delegates rated the bone model workshop cases as good or very good for the acetabular course, and 88% for the femoral course. Discussion. This course has been shown to enhance learning of surgical techniques and skills in complex hip surgery. Conclusion. We have developed a novel, effective and low cost training simulation method using pathological dry bone models for complex and revision hip arthroplasty which could be developed for other anatomical areas

Inserting screws into the vertebral pedicles is a challenging step in spinal fusion and scoliosis surgeries. Errors in placement can lead to neurological complications. The more experienced the surgeon, the better the accuracy of the screw placement. A physical training system would provide residents with the feel of performing pedicle cannulation before operating on a patient. The proposed system consists of realistic bone models mimicking the geometry and material properties of typical patients, coupled with a force feedback probe. The purpose of the present study was to determine the forces encountered during pedicle probing to aid in the development of this training system. We performed two separate investigations: [1] 15 participants (9 expert surgeons, 3 fellows and 3 residents) were asked to press a standard pedicle awl three times onto a mechanical scale, blinded to the force, demonstrating what force they would apply during safe pedicle cannulation and during unsafe cortical breach; [2] three experienced surgeons used a standard pedicle awl fitted with a one-degree of freedom load cell to probe selected thoracolumbar vertebrae of eight cadaveric specimens to measure the forces required during pedicle cannulation and deliberate breaching. A total of 42 pedicles were tested. Both studies had wide variations in the results, but were in general agreement. Cannulation (safe) forces averaged approximately 90 N (20 lb) whereas breach (unsafe) forces averaged approximately 135–155 N (30–35 lb). The lowest average forces in the cadaveric study were for pedicle cannulation, averaging 86 N (range, 23–125 N), significantly lower (p<0.001) than for anterior breach (135 N; range, 80–195 N); medial breach (149 N; range, 98–186 N) and lateral breach (157 N; range, 114–228 N). There were no significant differences between the breach forces (p>0.1). Cannulation forces were on average 59% of the breach forces (range, 19–84%) or conversely, breach forces were 70% higher than cannulation forces. To our knowledge, these axial force data are the first available for pedicle cannulation and breaching. A large range of forces was measured, as is experienced clinically. Additional testing is planned with a six-degree-of-freedom load cell to determine all of the forces and moments involved in cannulation and breaching, throughout the thoracolumbar spine. These results will inform the development of a realistic bone model as well as a breach prediction algorithm for a physical training system for spine surgery

Introduction: The Foundation Programme was implemented across the United Kingdom in 2005 and aims to “bridge the gap between medical school and specialty/general practice training.” Musculoskeletal complaints are the single most common reason for patients seeking medical attention and it is imperative that all clinicians should have at least a basic competency in musculoskeletal medicine. Aim: To determine if Foundation Programmes give junior doctors sufficient training to deal competently with musculoskeletal complaints. Methods: We prospectively enrolled junior doctors at the completion of their Foundation Programme. They were assessed using the Freedman and Bernstein musculoskeletal examination tool- the only validated method of assessing musculoskeletal medicine knowledge currently available. Passing this test only implies a basic level of competence in musculoskeletal medicine. Results: We recruited 112 junior doctors from across the United Kingdom. Only 8.9% of those recruited passed the assessment. Significantly higher mean scores were obtained by those with Foundation Programme exposure to Orthopaedics- 62% vs. 51.6% (p=0.005), an interest in Orthopaedics as a career- 64.8% vs. 52.8% (p=0.026) and those who felt that they had gained adequate Foundation Programme exposure to musculoskeletal medicine- 64% vs. 51.6% (p=0.0014). Those who were interested in General Practice obtained significantly lower scores than the rest of the group- 48.4% vs. 55.6% (p=0.009). Orthopaedics, internal medicine and general practice were the future specialty interest of 6%, 29% and 36% respectively. Only 15% had any Foundation Programme exposure to Orthopaedics and only 13% felt they had been given adequate exposure to musculoskeletal medicine. Conclusions: Foundation Programmes are currently failing to ensure junior doctors entering specialty training have a basic competence in musculoskeletal medicine. Given the high prevalence of musculoskeletal conditions encountered by most clinicians this is unacceptable and steps must be taken to improve the quality of Foundation Programme training in musculoskeletal medicine

Quality assurance for training in trauma and orthopaedics was provided by the JCHST through the SAC for Trauma and Orthopaedics. To date there have been written SAC standards; some are compulsory and others advisory and will generate requirements or recommendations to change if unmet on inspection. There has been a major change in the way postgraduate training is monitored and quality assured, with the formation of the PMETB, which now has the combined responsibility for all postgraduate training. The aims and objectives of our study were to measure the effectiveness of the current quality assurance system for training in Trauma and Orthopaedics, and to determine the reduction in the number of unmet compulsory standards at the end of the visits process and how effectively these requirements were implemented. We also identified the deficiencies in each component of training and determined the current general profile of the quality of training in Trauma and Orthopaedics. The inspection visits, progress and revisit reports were collected from training regions that were visited after the standards were implemented. In 109 units, in the 3 years studied, the inspection process reduced the overall unmet standards from a mean of 14.8% (10.3-19.2%) to 8.9% (6.5%-12.7%). The number of unmet requirement per unit fell from 4.6 to 2.8 (p<0.05). 27% of units did not improve. Overall 15% of standards were deficient, least in Scottish units and most in Irish units. Currently registrars do 1.4 trauma lists, 2.8 elective lists, 1.3 fracture clinics and 2.1 elective clinics per week. This is the first multi-regional study of a national accreditation process. Quality assurance requires standards setting and rectification. These findings are important for the imminent restructuring by the Postgraduate Medical Education Board

Introduction. The education of residents in the proper placement of pedicle screws is key to the safety of the surgery. The more experienced the surgeon, the more accurately the pedicle screws tend to be placed. A physical bone model, with properties and tactile feel similar to human bone, was developed with the intention of using the bone model to train residents in pedicle screw placement. The purpose of this study was to test whether the model improves the performance of orthopaedic residents when cannulating spinal pedicles, as judged by the number of breaches, and to gain feedback from the residents on their experiences. Materials and Methods. Six orthopaedic residents were recruited, with ethics approval. Prior to testing, the residents were given an instructional video describing the correct cannulation of a lumbar vertebra. The residents were each provided with 12 bones mounted in holders: 3 for initial skills assessment, 6 for free practice, and 3 for final skills assessment. In the pre- and post-practice sets, the 3 bone models had different properties: weak, normal and strong. The residents were asked to complete both pre and post-testing questionnaires. The number of breaches was counted in initial and final bone testing. The forces for each bone model were compared using an ANOVA; these were followed by post-hoc t-tests if significant (p<0.05). Results. All but one of the residents improved the number of breaches with practice, and the one that did not improve did not make the same breaches twice. The total number of breaches in the final testing (14) was lower than in the initial testing (31). The entry points chosen by the residents were all deemed appropriate as per the video instruction. The resident with the most experience had the least number of breaches; the resident with the least amount of experience had the most breaches. Discussion. The reduction of the number of breaches between the initial and final testing indicates that the residents did learn. Overall the response from the residents was positive; they all indicated they would like to have the simulator as part of their training; most even indicated an interest to use them outside of training hours. Almost all indicated that the bones felt more realistic than those currently available (if they were aware of them). Positively, the more surgical experience the resident had, the more their survey responses indicated a positive impression of the bones

Introduction. There have been concerns regarding the quality of training received by Orthopaedic trainees. There has been a reduction in working hours according to the European working times directive. National targets to reduce surgical waiting lists has increased the workload of consultants, further reducing the trainees' surgical experience. Navigation assisted procedures are successfully used in orthopaedics and provides useful feedback to the surgeon regarding precision of implant placement. We investigated the use of navigation aids as an alternative source of training surgical trainees. Methods. We choose a navigation assisted knee replacement (TKR) model for this study. A first year Orthopaedic registrar level trainee was taught the TKR procedure by a scrubbed consultant in 5 cases. He was then trained in use of non-CT based navigation surgery. The Trainee then performed navigation assisted non-complex primary TKR surgery. A consultant Orthopaedic surgeon was available throughout for advice and support. Data collected included pre and post procedure valgus and varus alignment of the knee, total operative time and WOMAC scores pre and post operatively. Results. A total of 42 TKRs were performed. Intra-operative review by the consultant surgeon was necessary on 3 occasions in the first 10 cases and two occasions in the remaining cases. The average operative time reduced from 184.25 minutes in the first 10 cases to 163.11 minutes in the next 20 cases and 150.33 minutes in the next 12 cases. The varus/valgus alignment was corrected to within 8 degrees in all cases. A significant improvement in WOMAC scores was recorded for all patients (p< 0.05). Conclusion. We believe that this model can be used as a training aid in various orthopaedic surgical procedures

Introduction: Despite worldwide vaccination programmes Polio is still endemic in some developing countries. Numerous new cases of polio are seen every year in India resulting in significant childhood deformity. The Rotary Club funds voluntary camps aimed at correcting deformities in children. I was part of the surgical team in Jan 2007 led by Mr. J. Clegg. Clinical experience: Some 141 procedures were carried out in 3 days, 99 by SPR’s under senior supervision. The most frequent procedure was a supra-condylar femoral osteotomy, followed by hip and knee soft tissue releases. For more complex operations we assisted or observed. Some deformity corrections were for non-polio cases. Interesting cases in the OPD included skeletal dysplasias, rickets and congenital deformities. Conclusion: At the time where MMC restricts overseas training opportunities, I believe this type of mini-fellowship provides valuable experience. Training programmes should have such opportunities available to all trainees

British military forces remain heavily committed in both Iraq and Afghanistan. A recent workload analysis from Op HERRICK identified a high surgical workload, particularly orthopaedic, under the care of a sole consultant orthopaedic surgeon. There are no orthopaedic training posts in UK that consistently provide training in ballistic trauma. In order to prepare Military orthopaedic trainees for future deployment, a new orthopaedic registrar post, on Op HERRICK, was created. Prospective analysis of trainee and trainer operative logbooks, between Jan 27th and March 24th 2008, was performed. Records were kept of orthopaedic and postgraduate teaching schedules, audit and research projects and all OCAP training assessments. One hundred and fifty-seven cases and 272 procedures were performed during the study period. Sixty-two per cent of cases were orthopaedic. Fourteen major amputations were performed and 7 external fixators applied. Five fasciotomies, 9 skeletal traction pins were inserted and 7 skin grafting procedures were performed. Limb debridement was the most common procedure (n=59). Eleven per cent of cases were children and 50 per cent of cases were emergencies. Thirty-eight per cent of cases were performed out of hours (18.00–08.00 hrs). Mean operating hours per week was 35 hrs. Four Procedure Based Assessments were performed and 16 hours of postgraduate education was conducted during the deployment. Two major audits were initiated and five publications were prepared, one has already been accepted for publication. Trainee exposure to high-energy transfer trauma is high when compared to that seen in the NHS. The numbers of certain index procedures, such as external fixation, is similar to those achieved by an average orthopaedic trainee in six years of higher surgical training. The opportunity for one-on-one training exceeds that available in the NHS and learning and academic opportunities are maximised due to the close working environment

Introduction: Most surgeons agree on basic parameters defining a successful joint replacement procedure. However, the process of acquiring the skills to achieve this level of success on a reproducible basis is much less straightforward. In reality, it is generally not possible to impart surgical training without some level of risk to the patient, particularly if a particular trainee or procedure has a long learning curve. In an attempt to address these issues, we have developed a new computer-based training system to measure the technical results of hip and knee replacement surgery in both the operating room and the Bioskills Lab. Description of the System: This system utilizes Surgical Navigation technology combined with data analysis and display routines to monitor the position and alignment of instruments and implants during the procedure in comparison with a preoperative plan. For bioskills training, the surgeon develops a preoperative plan on a computer workstation using accurate 3D computer models of the bones and appropriate implants. The surgeon then performs the entire procedure using the cadaver or sawbone model. During the procedure, the position and orientation of the bones, each surgical instrument, and the trial components are measured with a three-dimensional motion analysis system. Through analysis of this data, the surgeon is able to view each step of the surgical procedure, the placement of each instrument with respect to each bone, and the consequences of each surgical decision in terms of the final placement of the prosthetic components When errors are detected in the implementation of the preoperative plan, the surgeon is able to replay each step of the procedure to examine the precise placement of each instrument with respect to each bone and the consequences of each surgical decision in terms of leg length, alignment and range-of-motion. Conclusions: This system allows us to measure the technical success of a surgical procedure in terms of quantifiable geometric, spatial, kinematic or kinetic parameters. It also provides postoperative feedback to the surgeon by demonstrating the specific contributions of each step of the surgical procedure to deviations in final alignment or soft tissue instability. This approach allows surgeons to be trained outside the operating room prior to patient exposure. Once these skills have been developed, the surgeon is able to operate freely in the operating room without the risks associated with traditional surgical training, or the expense associated with intraoperative Surgical Navigation. The value of this approach in the training and accreditation of orthopedic staff warrants further investigation

Purpose: Few opportunities exist for physicians to easily obtain immediate insights or solicit direct advice from a respected peer on a complicated case. As a result, physicians end up relying heavily on journals, textbooks, and other dated resources that may prove to be dated or inadequate in addressing unique patient problems. Furthermore, the typical training modules available are limited to a one- or two-day experience. Often times this situation does not provide an adequate understanding of the surgical indications, techniques, and potential complications in the application of new technology. Consequently, many surgeons fail to adopt new technologies due to their lack of understanding of the application of such novel technologies. Recently, Reynolds et al studied the effect of peer collaboration among surgeons at a weekly surgery conference. They found that changes in surgical decision-making occurred in 12.5% of all cases reviewed and in 20% of the complex cases. However, collaboration should not be limited to weekly meetings or annual conferences. The Internet has introduced Collaborative Knowledge Networks (CKNs) that allow communities of surgeons to collaborate virtually on complex patient cases—allowing for rapid, bidirectional information. SpineConnect has surfaced as an example of a CKN that allows orthopedic spine surgeons to discuss surgical decisions. Method: We studied the use of Internet collaboration among spine surgeons using the SpineConnect website. We also compared the improvement in the adoption rate of novel technologies using technology fellowships versus traditional training modules. These fellowships use both in-person and virtual collaboration through the Spine-Connect platform as a new means of training physicians. Results: Using the SpineConnect website, surgical decision-making and planning was altered in 34% of active users and 90% agreed that the ability to collaborate with their peers, using a dedicated website, has improved their ability to practice spinal surgery. Continuous communication and dialogue resulting from the technology training fellowships encouraged better understanding of surgical indications, a greater comprehension of surgical technique, and a mechanism to discuss and solve complications. When such fellowships were implemented, we found a 30% improvement in adoption rate over traditional training modules. Conclusion: The treatment of spine surgery patients has benefited from the utilization of collaborative platforms such as SpineConnect. In spine surgeon training and education, we found that CKNs promoted better surgical decision-making and increased understanding of new technology application