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

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

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

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. Visual representation help make the ever-increasing data more attractive, thought provoking and informative. In the field of surgical training, Procedure Based Assessment is a structured method of assessing surgical performance and skills of trainees in the UK and is a valuable tool for trainers in the Annual Review of Competence Progression. Trainers can view PBA's on the online-based Intercollegiate Surgical Curriculum Programme individually in a long-form format with no visual representation. Aim. To assess the effect of an originally devised EVR tool of PBA's in the context of ARCP on 10 aspects including speed of assessment, assimilation of data, ease of interpretation and identification of trainees’ weaknesses and strengths. Methodology. 1) ISCP PBA data collected for three volunteered specialty trainees (ST4, ST5 & ST6) enrolled in Warwick Trauma and Orthopaedic training programme, for a six-month period from 1st July 2013 till 31st December 2013. 2) An EVR was generated using Tableau Desktop software, and two other EVR's originally devised to visually represent the trainees’ PBA's and integrated into three interactive PDF files. 3) Twelve trainer consultants participated in a mock ARCP and rated their experience in assessing the trainee's using the new EVR method compared to the ISCP website on three surveys. 4) A mock ARCP was set up for 12 consultants. To minimise bias, six assessors were randomised into two equal groups. Groups A were asked to use the ISCP website to formulate an ARCP decision and then use the EVR interactive tool. Group B used the EVR tool followed by browsing the ISCP website. 5) Assessors rated their experience after using each method and also at the end of the mock ARCP on three surveys. Responses recorded on a Visual Analogue Scale and statistically analysed using non-parametric a two-tailed Mann Whitney U test. Results. Comparing responses to the EVR and ISCP surveys shows that users thought that using the EVR tool is more useful, accessible, easy to learn and use, time efficient and appealing. It also allowed them to better identify trainees’ areas of strengths and weaknesses and formulate a final ARCP outcome decision in relation to PBA's (p < 0.001). Strong agreement to develop the EVR tool and have incorporated into the current ISCP website have been demonstrated (p < 0.001). Comparison of total responses to the EVR and ISCP surveys between group A and group B showed no significant statistical difference. Conclusion. The project shows that Enhanced Visual Representation tool has the potential to be a positive addition to the ISCP website to improve the process of surgical training and feedback

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

Background. Hip fractures affect 1.6 million people globally per annum, associated with significant morbidity and mortality. A large proportion are extracapsular neck of femur fractures, treated with the dynamic hip screw (DHS). Mechanical failure due to cut-out is seen in up to 7% of DHS implants. The most important predictor of cut-out is the tip-apex distance (TAD), a numerical value of the lag screw”s position in the femoral head. This distance is determined by the psychomotor skills of the surgeon guided by fluoroscopic imaging in theatre. With the current state of surgical training, it is harder for junior trainees to gain exposure to these operations, resulting in reduced practice. Additionally, methods of simulation using workshop bones do not utilise the imaging component due to the associated radiation risks. We present a digital fluoroscopy software, FluoroSim, a realistic, affordable, and accessible fluoroscopic simulation tool that can be used with workshop bones to simulate the first step of the DHS procedure. Additionally, we present the first round of accuracy tests with this software. Methods. The software was developed at the Royal National Orthopaedic Hospital, London, England. Two orthogonally placed cameras were used to track two coloured markers attached to a DHS guide-wire. Affine transformation matrices were used in both the anterior-posterior (AP) and cross table lateral (CTL) planes to match three points from the camera image of the workshop bone to three points on a pre-loaded hip radiograph. The two centre points of each marker were identified with image processing algorithms and utilised to digitally produce a line representing the guide-wire on the two radiographs. To test the accuracy of the system, the software generated 3D guide-wire apex distance (GAD) (from the tip of the guide-wire to a marker at the centre of calibration) was compared to the same distance measured with a digital calliper (MGAD). In addition, the same accuracy value was determined in a simulation scenario, from 406 attempts by 67 medical students. Results. The median absolute inaccuracy of FluoroSim with 270 measurements was 3.35mm (IQR = [1.15mm, 6.53mm]). The absolute inaccuracy showed a graded increase the further away the tip of the guide-wire was from the centre of calibration; MGAD ≤10mm, median absolute inaccuracy = 1.53mm; MGAD 10mm<x≤20mm, median absolute inaccuracy = 4.97mm; MGAD >20mm, median absolute inaccuracy = 7.23mm. Comparison between all three groups reached significance (p < 0.001). In a simulation scenario with medical students, FluoroSim had a significantly greater median absolute inaccuracy of 4.79mm compared to the testing scenario (p < 0.001). Conclusion. FluoroSim is a safe and inexpensive digital imaging adjunct to workshop bones simulation. To our knowledge this technology has not been explored in the context of DHS simulation, and has the potential to be extended to other orthopaedic procedures

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.

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.

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.

Anterior approach total hip arthroplasty (AA-THA) has a steep learning curve, with higher complication rates in initial cases. Proper surgical case selection during the learning curve can reduce early risk. This study aims to identify patient and radiographic factors associated with AA-THA difficulty using Machine Learning (ML).

Consecutive primary AA-THA patients from two centres, operated by two expert surgeons, were enrolled (excluding patients with prior hip surgery and first 100 cases per surgeon). K- means prototype clustering – an unsupervised ML algorithm – was used with two variables - operative duration and surgical complications within 6 weeks - to cluster operations into difficult or standard groups.

Radiographic measurements (neck shaft angle, offset, LCEA, inter-teardrop distance, Tonnis grade) were measured by two independent observers. These factors, alongside patient factors (BMI, age, sex, laterality) were employed in a multivariate logistic regression analysis and used for k-means clustering. Significant continuous variables were investigated for predictive accuracy using Receiver Operator Characteristics (ROC).

Out of 328 THAs analyzed, 130 (40%) were classified as difficult and 198 (60%) as standard. Difficult group had a mean operative time of 106mins (range 99–116) with 2 complications, while standard group had a mean operative time of 77mins (range 69–86) with 0 complications. Decreasing inter-teardrop distance (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.95–0.99, p = 0.03) and right-sided operations (OR 1.73, 95% CI 1.10–2.72, p = 0.02) were associated with operative difficulty. However, ROC analysis showed poor predictive accuracy for these factors alone, with area under the curve of 0.56. Inter-observer reliability was reported as excellent (ICC >0.7).

Right-sided hips (for right-hand dominant surgeons) and decreasing inter-teardrop distance were associated with case difficulty in AA-THA. These data could guide case selection during the learning phase. A larger dataset with more complications may reveal further factors.

Global surgical literature suggests that female trainees have less operative autonomy than their male counterparts. This pilot study had the primary objective to identify difference in autonomy by gender, and to power a national study to carry out further quantitative and qualitative research on this.

This was a retrospective, cross-sectional study utilising eLogbook data for all orthopaedic trainees (ST2-8) and consultants with CCT date 2016–2021 in a single Scottish deanery. The primary outcome measure was percentage of procedures undertaken as lead surgeon. 15 trainees and four recent consultants participated, of which 12 (63%) were male (mean grade 5.2), and 7 (37%) were female (mean grade 4.3). Trainees were lead surgeon on 64% of procedures (17595/27558), with autonomy rising with grade (37% ST1 to 85% ST8, OR 9.4). Operative autonomy was higher in male vs female trainees (66.5% and 61.4% respectively, p=<0.0001), with female trainees more likely to operate with a supervisor present (STU/S vs P/T, f 48%:13%, m 45%:20%).

This pilot study found that there was a significant difference in operative autonomy between male and female trainees, however this may be explained by differences in mean grade of male vs female trainees. Five trainees took time OOT, 4/5 of whom were female. Extension to a national multi-centre study should repeat the quantitative method of this study with additional qualitative analysis including assessing effect of time OOT to explore the reason for any gender discrepancies seen across different deaneries in the UK.

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

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

Background

Hip fractures cause significant morbidity and mortality, affecting 70,000 people in the UK each year. The dynamic hip screw (DHS) is used for the osteosynthesis of extracapsular neck of femur fractures, a procedure that requires complex psychomotor skills to achieve optimal lag screw positioning. The tip-apex distance (TAD) is a measure of the position of the lag screw from the apex of the femoral head, and is the most comprehensive predictor of cut-out (failure of the DHS construct). To develop these skills, trainees need exposure to the procedure, however with the European Working Time Directive, this is becoming harder to achieve. Simulation can be used as an adjunct to theatre learning, however it is limited. FluoroSim is a digital fluoroscopy simulator that can be used in conjunction with workshop bones to simulate the first step of the DHS procedure (guide-wire insertion) using image guidance. This study assessed the construct validity of FluoroSim. The null hypothesis stated that there would be no difference in the objective metrics recorded from FluoroSim between users with different exposure to the DHS procedure.

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.

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.

Introduction: In August 2007, the Department of Health initiative Modernising Medical Careers was implemented. This was a system of reform and development in postgraduate medical education and training. In preparation for the changes, the SAC for T& O outlined a new curriculum. The emphasis of early training, StR years 1 and 2, was to be trauma. We aim to identify how effectively the SAC proposals are being applied, and what difference this makes to the trainees’ operative experience? Furthermore, how do the new posts compare to the historic SHO models?

Methods: A survey carried out by BOTA allowed us to assess post compliance with the SAC recommendations. A compliant job was defined as trauma based for 50% or more of working time. Consent was obtained to evaluate the eLogbooks of trainees in compliant and non-compliant jobs, along with registrars who had previously held traditional SHO grade posts. Overall operative experience over a specified 4 month time period was examined, with focus on routine trauma procedures.

Results: The results of the BOTA and SAC survey revealed that 45% of the new orthopaedic posts were compliant with curriculum guidelines. The eLogbooks of 92 individuals were analysed; 28 historical posts, 34 compliant and 30 non-compliant. The mean total number of recorded entries by trainees in the 4 month period was 73.2 in the historic group, 90.5 in the compliant and 87.3 in the non-compliant job group. The corresponding numbers of trauma operations were 35.7, 48.4 and 41.5.

Conclusions: Operative experience has improved since the introduction of the new curriculum. The new posts are offering more operative and in particular trauma exposure than traditional SHO jobs. If jobs can be restructured such that they all comply with the SAC, educational opportunities in the early years will be maximised.

Since the emergence of the COVID-19 pandemic, the NHS has been under unprecedentedpressure. Elective surgery had ceased, and trauma surgery has decreased dramatically. Surgical training is multi-faceted and requires a specialist trainee to have a timetable which includes regular elective non-emergency operating, trauma operating and training in outpatient clinics. Consequently, training in theatre and the achievement of operative numbers and index procedures had not been possible for Trauma and Orthopaedic (T&O) specialist trainees. The Joint Committee on Surgical Training (JCST) has clear training index requirements for all T&O specialist trainees. In this study, we surveyed specialist trainees in the North West London deanery against the annual requirements set by the JCST guidelines. In addition, we retrospectively assessed the total number of trauma referrals and operations scheduled in our unit during the COVID-19 outbreak compared to that one year previously. The aim of this study is to objectively assess the effect the pandemic has on T&O specialist training. A total of 24 responses were collected from specialist trainees. The results of the survey showed 87% of trainees believed that their training had been affected. 75% of trainees felt they were not on track to meet operative numbers for the year, and 71% felt index number achievement had been affected. Trauma case numbers dropped by 20% compared to that one year previously. We recommend timely, planned and conscientious remediation for specialist trainees’ educational requirements. Specialist trainees must take responsibility for their training and use of additional educational opportunities. Clinical supervisors and training programme directors must provide additional support and guidance to achieve ARCP outcomes however in some scenarios extension of training may be necessary

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

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

The use of artificial intelligence (AI) is rapidly growing across many domains, of which the medical field is no exception. AI is an umbrella term defining the practical application of algorithms to generate useful output, without the need of human cognition. Owing to the expanding volume of patient information collected, known as ‘big data’, AI is showing promise as a useful tool in healthcare research and across all aspects of patient care pathways. Practical applications in orthopaedic surgery include: diagnostics, such as fracture recognition and tumour detection; predictive models of clinical and patient-reported outcome measures, such as calculating mortality rates and length of hospital stay; and real-time rehabilitation monitoring and surgical training. However, clinicians should remain cognizant of AI’s limitations, as the development of robust reporting and validation frameworks is of paramount importance to prevent avoidable errors and biases. The aim of this review article is to provide a comprehensive understanding of AI and its subfields, as well as to delineate its existing clinical applications in trauma and orthopaedic surgery. Furthermore, this narrative review expands upon the limitations of AI and future direction. Cite this article: Bone Joint Res 2023;12(7):447–454

Aims. Periacetabular osteotomy (PAO) is widely recognized as a demanding surgical procedure for acetabular reorientation. Reports about the learning curve have primarily focused on complication rates during the initial learning phase. Therefore, our aim was to assess the PAO learning curve from an analytical perspective by determining the number of PAOs required for the duration of surgery to plateau and the accuracy to improve. Methods. The study included 118 consecutive PAOs in 106 patients. Of these, 28 were male (23.7%) and 90 were female (76.3%). The primary endpoint was surgical time. Secondary outcome measures included radiological parameters. Cumulative summation analysis was used to determine changes in surgical duration. A multivariate linear regression model was used to identify independent factors influencing surgical time. Results. The learning curve in this series was 26 PAOs in a period of six months. After 26 PAO procedures, a significant drop in surgical time was observed and a plateau was also achieved. The mean duration of surgery during the learning curve was 103.8 minutes (SD 33.2), and 69.7 minutes (SD 18.6) thereafter (p < 0.001). Radiological correction of acetabular retroversion showed a significant improvement after having performed a total of 93 PAOs, including anteverting PAOs on 35 hips with a retroverted acetabular morphology (p = 0.005). Several factors were identified as independent variables influencing duration of surgery, including patient weight (β = 0.5 (95% confidence interval (CI) 0.2 to 0.7); p < 0.001), learning curve procedure phase of 26 procedures (β = 34.0 (95% CI 24.3 to 43.8); p < 0.001), and the degree of lateral correction expressed as the change in the lateral centre-edge angle (β = 0.7 (95% CI 0.001 to 1.3); p = 0.048). Conclusion. The learning curve for PAO surgery requires extensive surgical training at a high-volume centre, with a minimum of 50 PAOs per surgeon per year. This study defined a cut-off value of 26 PAO procedures, after which a significant drop in surgical duration occurred. Furthermore, it was observed that a retroverted morphology of the acetabulum required a greater number of procedures to acquire proficiency in consistently eliminating the crossover sign. These findings are relevant for fellows and fellowship programme directors in establishing the extent of training required to impart competence in PAO. Cite this article: Bone Joint J 2024;106-B(4):336–343

Aims. Manual impaction, with a mallet and introducer, remains the standard method of installing cementless acetabular cups during total hip arthroplasty (THA). This study aims to quantify the accuracy and precision of manual impaction strikes during the seating of an acetabular component. This understanding aims to help improve impaction surgical techniques and inform the development of future technologies. Methods. Posterior approach THAs were carried out on three cadavers by an expert orthopaedic surgeon. An instrumented mallet and introducer were used to insert cementless acetabular cups. The motion of the mallet, relative to the introducer, was analyzed for a total of 110 strikes split into low-, medium-, and high-effort strikes. Three parameters were extracted from these data: strike vector, strike offset, and mallet face alignment. Results. The force vector of the mallet strike, relative to the introducer axis, was misaligned by an average of 18.1°, resulting in an average wasted strike energy of 6.1%. Furthermore, the mean strike offset was 19.8 mm from the centre of the introducer axis and the mallet face, relative to the introducer strike face, was misaligned by a mean angle of 15.2° from the introducer strike face. Conclusion. The direction of the impact vector in manual impaction lacks both accuracy and precision. There is an opportunity to improve this through more advanced impaction instruments or surgical training. Cite this article: Bone Joint Res 2024;13(4):193–200

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

Abstract. Objectives. Accurate orientation of the acetabular component during a total hip replacement is critical for optimising patient function, increasing the longevity of components, and reducing the risk of complications. This study aimed to determine the validity of a novel VR platform (AescularVR) in assessing acetabular component orientation in a simulated model used in surgical training. Methods. The AescularVR platform was developed using the HTC Vive® VR system hardware, including wireless trackers attached to the surgical instruments and pelvic sawbone. Following calibration, data on the relative position of both trackers are used to determine the acetabular cup orientation (version and inclination). The acetabular cup was manually implanted across a range of orientations representative of those expected intra-operatively. Simultaneous readings from the Vicon® optical motion capture system were used as the ‘gold standard’ for comparison. Correlation and agreement between these two methods was determined using Bland-Altman plots, Pearson's correlation co-efficient, and linear regression modelling. Results. A total of 55 separate orientation readings were obtained. The mean average difference in acetabular cup version and inclination between the Vicon and VR systems was 3.4° (95% CI: −3–9.9°), and −0.005° (95% CI: −4.5–4.5°) respectively. Strong positive correlations were demonstrated between the Vicon and VR systems in both acetabular cup version (Pearson's R = 0.92, 99% CI: 0.84–0.96, p<0.001), and inclination (Pearson's R = 0.94, 99% CI: 0.88–0.97, p<0.001). Using linear regression modelling, the adjusted R. 2. for acetabular version was 0.84, and 0.88 for acetabular inclination. Conclusion. The results of this study indicate that the AescularVR platform is highly accurate and reliable in determining acetabular component orientation in a simulated environment. The AescularVR platform is an adaptable tracking system, which may be modified for use in a range of simulated surgical training and educational purposes, particularly in orthopaedic surgery. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Aims. The principles of evidence-based medicine (EBM) are the foundation of modern medical practice. Surgeons are familiar with the commonly used statistical techniques to test hypotheses, summarize findings, and provide answers within a specified range of probability. Based on this knowledge, they are able to critically evaluate research before deciding whether or not to adopt the findings into practice. Recently, there has been an increased use of artificial intelligence (AI) to analyze information and derive findings in orthopaedic research. These techniques use a set of statistical tools that are increasingly complex and may be unfamiliar to the orthopaedic surgeon. It is unclear if this shift towards less familiar techniques is widely accepted in the orthopaedic community. This study aimed to provide an exploration of understanding and acceptance of AI use in research among orthopaedic surgeons. Methods. Semi-structured in-depth interviews were carried out on a sample of 12 orthopaedic surgeons. Inductive thematic analysis was used to identify key themes. Results. The four intersecting themes identified were: 1) validity in traditional research, 2) confusion around the definition of AI, 3) an inability to validate AI research, and 4) cautious optimism about AI research. Underpinning these themes is the notion of a validity heuristic that is strongly rooted in traditional research teaching and embedded in medical and surgical training. Conclusion. Research involving AI sometimes challenges the accepted traditional evidence-based framework. This can give rise to confusion among orthopaedic surgeons, who may be unable to confidently validate findings. In our study, the impact of this was mediated by cautious optimism based on an ingrained validity heuristic that orthopaedic surgeons develop through their medical training. Adding to this, the integration of AI into everyday life works to reduce suspicion and aid acceptance. Cite this article: Bone Jt Open 2023;4(9):696–703

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

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

Augmented reality simulators offer opportunities for practice of orthopaedic procedures outside of theatre environments. We developed an augmented reality simulator that allows trainees to practice pinning of paediatric supracondylar humeral fractures (SCHF) in a radiation-free environment at no extra risk to patients. The simulator is composed of a tangible child's elbow model, and simulated fluoroscopy on a tablet device. The treatment of these fractures is likely one of the first procedures involving X-ray guided wire insertion that trainee orthopaedic surgeons will encounter. This study aims to examine the extent of improvement simulator training provides to real-world operating theatre performance. This multi-centre study will involve four cohorts of New Zealand orthopaedic trainees in their SET1 year. Trainees with no simulator exposure in 2019 - 2021 will form the comparator cohort. Trainees in 2022 will receive additional, regular simulator training as the intervention cohort. The comparator cohort's performance in paediatric SCHF surgery will be retrospectively audited using routinely collected operative outcomes and parameters over a six-month period. The performance of the intervention cohorts will be collected in the same way over a comparable period. The data collected for both groups will be used to examine whether additional training with an augmented reality simulator shows improved real-world surgical outcomes compared to traditional surgical training. This protocol has been approved by the University of Otago Health Ethics committee, and the study is due for completion in 2024. This study is the first nation-wide transfer validity study of a surgical simulator in New Zealand. As of September 2022, all trainees in the intervention cohort have been recruited along with eight retrospective trainees via email. We present this protocol to maintain transparency of the prespecified research plans and ensure robust scientific methods. This protocol may also assist other researchers conducting similar studies within small populations

In the last years, 3d printing has progressively grown and it has reached a solid role in clinical practice. The main applications brought by 3d printing in orthopedic surgery are: preoperative planning, custom-made surgical guides, custom-made im- plants, surgical simulation, and bioprinting. The replica of the patient's anatomy, starting from the elaboration of medical volumetric images (CT, MRI, etc.), allows a progressive extremization of treatment personalization that could be tailored for every single patient. In complex cases, the generation of a 3d model of the patient's anatomy allows the surgeons to better understand the case — they can almost “touch the anatomy” —, to perform a more ac- curate preoperative planning and, in some cases, to perform device positioning before going to the surgical room (i.e. joint arthroplasty). 3d printing is also commonly used to produce surgical cutting guides, these guides are positioned intraoperatively on given landmarks to guide the surgeon to perform a specific surgical act (bone osteotomy, bone resection, implant position, etc.). In total knee arthroplasty, custom-made cutting guides have been developed to help the surgeon align the femoral and tibial components to the pre-arthritic condition with- out the use of the intramedullary femoral guide. 3d printed custom-made implants represent an emerging alternative to biological reconstructions especially after oncologic resection surgery or in case of complex arthroplasty revision surgery. Custom-made implants are designed to re- place the original shape and size of the patient's bone and they allow an extreme personalization of the treatment for every single patient. Patient-specific surgical simulation is a new frontier that promises great benefits for surgical training. a solid 3d model of the patient's anatomy can faithfully reproduce the surgical complexity of the patient and it allows to generate surgical simulators with increasing difficulty to adapt the difficulties of the course with the level of the trainees performing structured training paths: from the “simple” case to the “complex” case

Primary total hip replacement (THR) is a successful and common operation which orthopaedic trainees must demonstrate competence in prior to completion of training. This study aimed to determine the impact of operating surgeon grade and level of supervision on the incidence of 1-year patient mortality and all-cause revision following elective primary THR in a large UK training centre. National Joint Registry (NJR) data for all elective primary THR performed in a single University Teaching Hospital from 2005–2020 were used, with analysis performed on the 15-year dataset divided into 5-year temporal periods (B1 2005–2010, B2 2010–2015, B3 2015–2020). Outcome measures were mortality and revision surgery at one year, in relation to lead surgeon grade, and level of supervision for trainee-led operations. 9999 eligible primary THR were undertaken, of which 5526 (55.3%) were consultant led (CL), and 4473 (44.7%) trainees led (TL). Of TL, 2404 (53.7%) were non-consultant supervised (TU), and 2069 (46.3%) consultant supervised (TS). The incidence of 1-year patient mortality was 2.05% (n=205), and all-cause revision was 1.11% (n=111). There was no difference in 1-year mortality between TL (n=82, 1.8%) and CL (n=123, 2.2%) operations (p=0.20, OR 0.78, CI 0.55–1.10). The incidence of 1-year revision was not different for TL (n=56, 1.3%) and CL (n=55, 1.0%) operations (p=0.15, OR 1.37, CI 0.89–2.09). Overall, there was no temporal change for either outcome measure between TL or CL operations. A significant increase in revision within 1-year was observed in B3 between TU (n=17, 2.7%) compared to CL (n=17, 1.0%) operations (p=0.005, OR 2.81, CI 1.35–5.87). We found no difference in 1-year mortality or 1-year all-cause revision rate between trainee-led primary THR and consultant-led operations over the entire fifteen-year period. However, unsupervised trainee led THR in the most recent 5-year block (2015–2020) has a significantly increased risk of early revision, mainly due to instability and prosthetic joint infection. This suggests that modern surgical training is having a detrimental effect on THR patient outcomes. More research is needed to understand the reasons if this trend is to be reversed

Aims. We aim to objectively assess the impact of COVID-19 on mean total operative cases for all indicative procedures (as outlined by the Joint Committee on Surgical Training (JCST)) experienced by orthopaedic trainees in the deanery of the Republic of Ireland. Subjective experiences were reported for each trainee using questionnaires. Methods. During the first four weeks of the nationwide lockdown due to COVID-19, the objective impact of the pandemic on each trainee’s surgical caseload exposure was assessed using data from individual trainee logbook profiles in the deanery of the Republic of Ireland. Independent predictor variables included the trainee grade (ST 3 to 8), the individual trainee, the unit that the logbook was reported from, and the year in which the logbook was recorded. We used the analysis of variance (ANOVA) test to assess for any statistically significant predictor variables. The subjective experience of each trainee was captured using an electronic questionnaire. Results. The mean number of total procedures per trainee over four weeks was 36.8 (7 to 99; standard deviation (SD) 19.67) in 2018, 40.6 (6 to 81; SD 17.90) in 2019, and 18.3 (3 to 65; SD 11.70) during the pandemic of 2020 (p = 0.043). Significant reductions were noted for all elective indicative procedures, including arthroplasty (p = 0.019), osteotomy (p = 0.045), nerve decompression (p = 0.024) and arthroscopy (p = 0.024). In contrast, none of the nine indicative procedures for trauma were reduced. There was a significant inter-unit difference in the mean number of total cases (p = 0.029) and indicative cases (p = 0.0005) per trainee. We noted that 7.69% (n = 3) of trainees contracted COVID-19. Conclusion. During the COVID-19 pandemic, the mean number of operative cases per trainee has been significantly reduced for four of the 13 indicative procedures, as outlined by the JCST. Reassignment of trainees to high-volume institutions in the future may be a plausible approach to mitigate significant training deficits in those trainees worst impacted by the reduction in operative exposure

Simulation in surgical training has become a key component of surgical training curricula, mandated by the GMC, however commercial tools are often expensive. As training budgets become increasingly pressurised, low-cost innovative simulation tools become desirable. We present the results of a low-cost, high-fidelity simulator developed in-house for teaching fluoroscopic guidewire insertion. A guidewire is placed in a 3d-printed plastic bone using simulated fluoroscopy. Custom software enables two inexpensive web cameras and an infra-red led marker to function as an accurate computer navigation system. This enables high quality simulated fluoroscopic images to be generated from the original CT scan from which the bone model is derived and measured guidewire position. Data including time taken, number of simulated radiographs required and final measurements such as tip apex distance (TAD) are collected. The simulator was validated using a DHS model and integrated assessment tool. TAD improved from 16.8mm to 6.6mm (p=0.001, n=9) in inexperienced trainees, and time taken from 4:25s to 2m59s (p=0.011). A control group of experienced surgeons showed no improvement but better starting points in TAD, time taken and number of radiographs. We have also simulated cannulated hip screws, femoral nail entry point and SUFE, but the system has potential for simulating any procedure requiring fluoroscopic guidewire placement e.g. pedicle screws or pelvic fixation. The low cost and 3D-printable nature have enabled multiple copies to be built. The software is open source allowing replication by any interested party. The simulator has been incorporated successfully into a higher orthopaedic surgical training program

Continuous technical improvement in spinal surgical procedures, with the aim of enhancing patient outcomes, can be assisted by the deployment of advanced technologies including navigation, intraoperative CT imaging, and surgical robots. The latest generation of robotic surgical systems allows the simultaneous application of a range of digital features that provide the surgeon with an improved view of the surgical field, often through a narrow portal. There is emerging evidence that procedure-related complications and intraoperative blood loss can be reduced if the new technologies are used by appropriately trained surgeons. Acceptance of the role of surgical robots has increased in recent years among a number of surgical specialities including general surgery, neurosurgery, and orthopaedic surgeons performing major joint arthroplasty. However, ethical challenges have emerged with the rollout of these innovations, such as ensuring surgeon competence in the use of surgical robotics and avoiding financial conflicts of interest. Therefore, it is essential that trainees aspiring to become spinal surgeons as well as established spinal specialists should develop the necessary skills to use robotic technology safely and effectively and understand the ethical framework within which the technology is introduced. Traditional and more recently developed platforms exist to aid skill acquisition and surgical training which are described. The aim of this narrative review is to describe the role of surgical robotics in spinal surgery, describe measures of proficiency, and present the range of training platforms that institutions can use to ensure they employ confident spine surgeons adequately prepared for the era of robotic spinal surgery. Cite this article: Bone Joint J 2020;102-B(5):568–572

Aims. To develop a core outcome set of measurements from postoperative radiographs that can be used to assess technical skill in performing dynamic hip screw (DHS) and hemiarthroplasty, and to validate these against Van der Vleuten’s criteria for effective assessment. Methods. A Delphi exercise was undertaken at a regional major trauma centre to identify candidate measurement items. The feasibility of taking these measurements was tested by two of the authors (HKJ, GTRP). Validity and reliability were examined using the radiographs of operations performed by orthopaedic resident participants (n = 28) of a multicentre randomized controlled educational trial (ISRCTN20431944). Trainees were divided into novice and intermediate groups, defined as having performed < ten or ≥ ten cases each for DHS and hemiarthroplasty at baseline. The procedure-based assessment (PBA) global rating score was assumed as the gold standard assessment for the purposes of concurrent validity. Intra- and inter-rater reliability testing were performed on a random subset of 25 cases. Results. In total, 327 DHS and 248 hemiarthroplasty procedures were performed by 28 postgraduate year (PGY) 3 to 5 orthopaedic trainees during the 2014 to 2015 surgical training year at nine NHS hospitals in the West Midlands, UK. Overall, 109 PBAs were completed for DHS and 80 for hemiarthroplasty. Expert consensus identified four ‘final product analysis’ (FPA) radiological parameters of technical success for DHS: tip-apex distance (TAD); lag screw position in the femoral head; flushness of the plate against the lateral femoral cortex; and eight-cortex hold of the plate screws. Three parameters were identified for hemiarthroplasty: leg length discrepancy; femoral stem alignment; and femoral offset. Face validity, content validity, and feasibility were excellent. For all measurements, performance was better in the intermediate compared with the novice group, and this was statistically significant for TAD (p < 0.001) and femoral stem alignment (p = 0.023). Concurrent validity was poor when measured against global PBA score. This may be explained by the fact that they are measuring difference facets of competence. Intra-and inter-rater reliability were excellent for TAD, moderate for lag screw position (DHS), and moderate for leg length discrepancy (hemiarthroplasty). Use of a large multicentre dataset suggests good generalizability of the results to other settings. Assessment using FPA was time- and cost-effective compared with PBA. Conclusion. Final product analysis using post-implantation radiographs to measure technical skill in hip fracture surgery is feasible, valid, reliable, and cost-effective. It can complement traditional workplace-based assessment for measuring performance in the real-world operating room . It may have particular utility in competency-based training frameworks and for assessing skill transfer from the simulated to live operating theatre. Cite this article: Bone Joint Open 2020;1-9:594–604

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

Surgical training in the UK is under increasing pressure with a high demand for service provision. This raises concerns about the resultant negative impact this is having on training opportunities for surgical trainees in theatre due to a high demand for surgical procedures to be performed expediently by consultants. This is due to the assumption that trainee take significantly longer time to operate in theatre and thus result in a slow progress of theatre lists. Our study evaluated the differences in operative time between orthopaedic trainees and orthopaedic consultants, as well as provide realistic timings for each stage encompassed within the entire duration a patient is in theatre. From our trauma unit electronic theatre database, we retrospectively collected data for six Joint Committee of Surgical Training (JCST) mandatory procedures. Information collected included patients' ASA grading, total surgical time and grade of surgeons. A total of 956 procedures were reviewed: 71.8% hip procedures, 14.2% intramedullary nail fixations and 14.2% ankle fixations. 46.2% and 53.8% of the procedures were performed by consultants and trainees as first surgeon, respectively. On average, consultants were found to be 13 minutes quicker in performing the hip procedures and this difference was found to be statically significant (p < 0.05). However, trainees were found to be quicker in performing intramedullary femoral nailings and simple ankle fixations, but consultant were faster at performing intramedullary tibial nailings and complex ankle fixations. However, the differences were not found to be statistically significant (p > 0.05)

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

Introduction. Simulation is increasingly perceived as an important component of surgical training. Cadaveric simulation offers an experience that can closely simulate operating on a living patient. We have explored the feasibility of providing cadaveric training for the whole curriculum for trauma and orthopaedic surgery speciality trainees, before they perform those operations on living patients. Methods. An eight station surgical training centre was designed and built adjacent to the mortuary of a University Hospital. Seven two-day courses for foot and ankle, knee, hip, spine, shoulder and elbow, hand and wrist, and trauma surgery were designed and delivered. These courses, designed for 16 trainees, were delivered by eight consultant trainers and a course director. Each was structured to allow every trainee to perform each standard operation in the curriculum for that respective subspecialty. We designed the courses to maximise simulated operating time for the trainees and to minimise cost. We surveyed trainers and trainees after the courses to qualitatively assess their value. Results. We found that it was possible to create a state-of-the-art surgical training centre in a University Hospital with a business model that could be replicated. It was possible to deliver cadaveric surgical training to trainees, early in their experience in that subspecialty, such that they learn the principles of each operation in the curriculum in the course of two days. This required some very intense work: for example the foot and ankle course included 30 surgical procedures. Trainees and trainers rated this experience as very high quality training and judge that it will substantially affect the safety and value of future training with living patients. Conclusion. We suggest that our findings support the idea of cadaveric training for all trainees before operating on living patients. We are implementing this in our training programme

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

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

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

Introduction. Studies have addressed the issue of increasing prevalence of work-related musculoskeletal (MSK) pain among different occupations. However, contributing factors to MSK pain have not been fully investigated among orthopaedic surgeons. Thus, this study aimed to approximate the prevalence and predictors of MSK pain among Saudi orthopaedic surgeons working in Riyadh, Saudi Arabia. Methods. A cross-sectional study using an electronic survey was conducted in Riyadh. The questionnaire was distributed through email among orthopaedic surgeons in Riyadh hospitals. Standardized Nordic questionnaires for the analysis of musculoskeletal symptoms were used. Descriptive measures for categorical and numerical variables were presented. Student’s t-test and Pearson’s χ2 test were used. The level of statistical significance was set at p ≤ 0.05. Results. The response rate was 80.3%, with a total number of 179 of Saudi orthopaedic surgeons (173 males and six females). Of our sample, 67.0% of the respondents complained of having MSK pain. The most commonly reported MSK pain was lower back (74.0%), followed by neck (58.2%). Age and body mass index were implicated in the development of more than one type of MSK pain. Increased years of experience (≥ 6 years) was linked to shoulder/elbow, lower back, and hip/thigh pain. Smoking is widely associated with lower back pain development, whereas physicians who do not smoke and exercise regularly reported fewer pain incidences. Excessive bending and twisting during daily practice have been correlated with increased neck pain. Conclusion. MSK pain was found to be common among Saudi orthopaedic surgeons. Further extensive research should be conducted to understand and analyze the risk factors involved and search for possible improvements to avoid further complications. However, ergonomics education during surgical training could be effective at modifying behaviors and reducing MSK pain manifestations

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

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

This study defines the patterns of perineal injury due to blast currently seen on operations. It refines our team-based surgical strategies of surgical resuscitation provides an evidence base for a perineal debridement - colonic diversion didactic on the Military Operational Surgical Training (MOST) course. The Joint Theatre Trauma Registry (JTTR) held at RCDM was examined from 1 January 2003 to 31 December 2010. Data abstracted included patient demographics, mechanism of injury, injury severity score (ISS), treatment, management, length of stay (LOS) and outcomes. Of 4807 military trauma patients, 118 (2.5%) had a recorded perineal injury, 56 died (48% all IED). Pelvic fractures were identified in 63 (53%) of which 17 (27%) survived. Mortality rates were significantly different between the combined perineal & pelvic fracture group compared to pelvic fracture & perineal injuries alone (41% & 18% respectively, p = 0.0001). Mean ISS for all patients was 41.03. Those with a pelvic fracture had a significantly higher ISS than those with perineal injuries alone (29.53 vs. 51.06, p = 0.0001). Recorded early antibiotic use was significantly more frequent in survivors (p = 0.0119). A literature review demonstrated the benefits of early feeding, emergent diversion, antibiotics, daily washouts and radical early debridement. Combined perineal injuries & pelvic fractures have the highest rate of mortality. Early aggressive management is essential to survival in this cohort. Our recommendations are immediate faecal diversion, aggressive initial debridement & early enteral feeding (in the deployed ITU after first surgery). These findings will enable the rapid provision of an evidence based training schedule to be incorporated into our pre-deployment surgical training program (MOST) to improve surgical team preparation and patient outcomes

Introduction. The efficacy of Virtual Reality (VR) as a teaching augment for arthroplasty has not been well examined for unfamiliar multistep procedures such as unicompartmental knee arthroplasty (UKA). This study sought to determine if VR improves surgical competence over traditional procedural preparation when performing a UKA. Methods. 22 Orthopaedic trainees were randomized to training sessions: 1) “VR group” with access to an immersive VR learning module that had been designed in conjunction with the manufacturer or 2) “Guide group” with access to manufacture's technique guide and surgical video. Both groups then performed a full UKA on SawBones models. Surgical competence was assessed via Objective Structures Assessment of Technical Skills (OSATS) validated rating system (max 25 points). Results. Participants equally distributed all training levels between groups. There was no difference in surgical times between VR and Guide groups (VR=43.0 vs Guide=42.4 mins; p=0.9). There was no difference in total OSATS score between groups (VR=14.2 vs Guide=15.7; p=0.59). There was also no difference between groups when sub-analysis was performed by training level. Most felt VR would be a useful tool for resident education (77%) and reported a likeliness to utilize VR for case preparation if available (86.4%). Conclusion. In a randomized controlled trial for trainees performing a complex, unfamiliar procedure (UKA), VR training demonstrated equivalent surgical competence to traditional technique guides and videos. Despite this, the majority of trainees find the technology beneficial and would use it if available. This project suggests as currently constructed, VR should be incorporated as an adjunct, rather than a replacement, to traditional surgical preparation/training methods

Aims

Ankle fracture fixation is commonly performed by junior trainees. Simulation training using cadavers may shorten the learning curve and result in a technically superior surgical performance.

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.

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.

Introduction. The demands placed upon joint surgeons are perhaps greatest when treating the revision arthroplasty patient, who present with complications demanding skill in diagnosis and evaluation, interpersonal communication and the technical aspects of the revision procedure. However, little information exists identifying which specific tasks in revision arthroplasty are most difficult for surgeons to master, and whether the greatest challenges arise from clinical, cognitive or technical facets of patient treatment. This study was undertaken to identify which tasks associated with revision total knee replacement (TKR) are perceived as most challenging to young surgeons and trainees to guide future efforts in surgical training and curriculum development. Methods. We developed an online survey instrument consisting of 69 items encompassing pre-operative, intraoperative, and post-operative tasks that preliminary studies identified as the essential components of revision TKR. These tasks encompassed 4 domains: clinical decision-making skills (n=9), interpersonal assessment and communication (n=7), surgical decision-making (n=35) and procedural surgical tasks (n=18). Respondents rated the difficulty of each item on a 5-level Likert scale, with an ordinal score ranging from 1 (“very easy”) to 5 (“very difficult”. The survey instrument was administered to a cohort of 109 US surgeons: 31 trainees enrolled in a joint fellowship program (Fellows) and 78 surgeons who had graduated from a joint fellowship program within the previous 10 years (Joint Surgeons). Using appropriate parametric and non-parametric tests, the responses were analyzed to examine the variation of reported difficulty of each of the 69 items, in addition to the nature of the task (cognitive, surgical, clinical and interpersonal), and differences between Fellows and Surgeons. Results. Both Fellows and Surgeons reported a wide variation in the difficulty of performing the tasks identified in each f the 4 domains. Fellows reported a higher average difficulty score than Surgeons (2.94 vs 2.74; p=0.032), corresponding to a greater frequency of tasks entailing some degree of difficulty (34.9% vs 24.4%, p<0.0001). Both groups experienced difficulty in performing tasks involving interpersonal interaction with patients (Fellows: 34.6% vs Surgeons: 34.3%, p=0.93). Fellows also found the technical aspects of revision surgery most challenging with 38.5% of items considered difficult compared to 28.7% for the Surgeon group (p<0.001). Highly significant differences between Fellows and Surgeons were also observed in facility with surgical decision making (p<0.001) and to a lesser extent, clinical decisions relating to patient care (% difficulty: p=0.0251). A compilation of the specific items cited as most difficult by the participants appears in Table 2. Conclusions. The young surgeons surveyed in this study reported difficulty in performing some tasks within both the clinical, cognitive and technical domains of revision knee arthroplasty. The high incidence of difficulty in tasks involving clinical decision-making and operative performance are characterized by a lack of accepted guidelines and the lack of a standard surgical practice. In general, our findings highlight the need for improvements in surgeon training to improve decision-making and procedural skills as part of the comprehensive management of patients undergoing revision knee arthroplasty. For any figures or tables, please contact authors directly

Aims

The number of females within the speciality of trauma and orthopaedics (T&O) is increasing. The aim of this study was to identify: 1) current attitudes and behaviours of UK female T&O surgeons towards pregnancy; 2) any barriers faced towards pregnancy with a career in T&O surgery; and 3) areas for improvement.

Recent advancements in biomaterial technology have created novel options for acetabular fixation in primary total hip arthroplasty (THA). For example, cementless acetabular fixation has become the preferred option, however, there is continued debate concerning whether long-term survivorship is comparable to that of cemented component fixation. Many doubts previously associated with early cementless designs have been addressed with newer features such as improved locking mechanisms, enhanced congruity between the acetabular liner and the shell, and the inclusion of highly cross-linked ultra-high molecular weight polyethylene (UHMWPE). Additionally, there has been increased utilization of new porous metals, titanium mesh, and hydroxyapatite (HA) coated implants. However, several retrieval studies have indicated that porous-coated cementless acetabular components can exhibit poor bony ingrowth. Many surgeons in Europe favor cemented fixation, where registry data is favorable for this interface. A surgeon's decision to use a cemented or cementless acetabular component is typically dependent on factors such as patient bone stock, surgical training, and experience. With the frequency of THAs expected to increase, it is particularly important for orthopaedic surgeons to be familiar with appropriate preoperative planning and component selection in an effort to achieve optimal outcomes. Therefore, this talk will outline and describe the options currently available for cementless and cemented acetabular fixation in primary total hip arthroplasty

Background. Radiation exposure remains a significant occupational hazard for Orthopaedic surgeons. There are no references values for trauma procedures performed with Image Intensifier (II). We aimed to determine and compare reference values for patient radiation exposure for common trauma operations, and to analyse the effect of surgeon grade on II usage. Methods. Data collected prospectively from 849 cases between 01/05/2013 and 01/10/2014 were analysed. Statistical analysis was performed to calculate reference values for dose area product (DAP), screening time (ST), and number of II images taken for common trauma procedures where n>9 (n=808). Results. Dynamic hip screw (DHS) fixation required significantly less radiation than proximal femoral nail (PFN) for intertrochanteric hip fractures for median DAP (668mG/cm2 vs 1040mG/cm2, p<0.001), ST (00:36 vs 00:48, p<0.001), and number of II images (65 vs 110, p<0.001). Radiation exposure was statistically significantly less when Consultant Orthopaedic surgeons were first surgeon compared to Staff grade doctors and Orthopaedic trainees for DAP (90.55mGy/cm2 vs 175.5mGy/cm2 vs 366.5mGy/cm2), screening time (00:26 vs 00:32 vs 00:36), and number of II images (49 vs 59 vs 66). Conclusions. We reported reference values for common trauma operations that are essential to enable monitoring of patient radiation exposure. PFN required greater radiation exposure than DHS for intertrochanteric hip fracture. Increased surgical experience lead to lower radiation exposure in trauma operations, which could be developed to assess trauma competence within surgical training. Level of evidence. III

Competition ratios for Core Surgical Training (CST) and Higher Specialist Training in Trauma & Orthopaedic (T&O) surgery have decreased over the last 5 years. Whilst multifactorial, one reason thought to contribute to career decision- making, is junior doctors' experience whilst working in that specialty. This study aimed to identify ‘who’ is currently working on the “1st on call” tier in T&O in the UK, and what clinical activities are undertaken. Collaborators were recruited between 12/09/2015 – 17/01/2016 via the BOTA networks. Data was prospectively collected between 18/01/2015 and 22/01/2015. Each collaborator completed a coded clinical activity diary for all doctors on the “1st on call” rota for T&O in their hospital. Activity parameters included doctor grade, rota gaps, operative and clinic exposure, on call activity, and ward cover. 221 collaborators submitted clinical activity data regarding 933 junior doctors from 100 T&O departments in the UK. 30 rota gaps were identified. The mean number of junior tier doctors was 9 (range 1–23). The “Lost Tribe” comprised Foundation Year 2 (26%), Core Surgical Trainee (19%), Trust Grade (20%), and locum doctors (13%), amongst other grades. During the study period, 2.5% of the ‘Lost Tribe’s' time was allocated to clinic, 2.7% to theatre, 27% to ward cover and 34.6% to zero sessions. Doctors-in-training make up a minority of the workforce and as such, the T&O profession need to do more to ensure that junior doctors are exposed to clinics and operative lists to specifically address the balance between training and service delivery

Aims

The aims of this study were to determine the success of a reconstruction algorithm used in major acetabular bone loss, and to further define the indications for custom-made implants in major acetabular bone loss.

Simulated learning is increasingly prevalent in many surgical training programs as medical education moves towards competency based curricula. In orthopaedic surgery, developmental dysplasia of the hip is a commonly treated diagnosis where the standard of care in patients less than six months of age is an orthotic device such as the Pavlik Harness. However, despite widespread use of the Pavlik Harness and the potential complications that may arise from inappropriate application, no formal educational methods exist. A video and model based simulated learning module for Pavlik Harness application was developed. Two novice groups (residents and allied health professionals) were exposed to the module and at pre-intervention, post-intervention and retention testing were evaluated on their ability to apply a Pavlik Harness to the model. Evaluations were completed using a previously validated Objective Structured Assessment of Technical Skill (OSATS) and a Global Rating Scale (GRS) specific to Pavlik Harness application. A control group who did not undergo the module was also evaluated at two time points to determine if exposure to the Pavlik Harness alone would affect ability. All groups were compared to a group of clinical experts who were used as a competency benchmark. Statistical analysis of skill acquisition and retention was conducted using t-tests and ANOVA. Exposure to the learning module improved resident and allied health professionals' competency in applying a Pavlik Harness (p<0.05) to the level of expert clinicians and this level of competency was retained one month after exposure to the module. Control subjects who were not exposed to the module did not improve nor did they achieve competency. The simulated learning module has been shown to be an effective tool for teaching the application of a Pavlik Harness and learners demonstrated retainable skills post intervention. This learning module will form the cornerstone of formal teaching for Pavlik Harness application in developmental dysplasia of the hip

Aims

This study aimed to answer the following questions: do 3D-printed models lead to a more accurate recognition of the pattern of complex fractures of the elbow?; do 3D-printed models lead to a more reliable recognition of the pattern of these injuries?; and do junior surgeons benefit more from 3D-printed models than senior surgeons?

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.

Aims

This study aimed to describe practice variation in the use of total hip arthroplasty (THA) for older patients with femoral neck fracture and to determine the association between patient, surgeon, and institution factors and treatment with THA.

Literature surrounding artificial intelligence (AI)-related applications for hip and knee arthroplasty has proliferated. However, meaningful advances that fundamentally transform the practice and delivery of joint arthroplasty are yet to be realized, despite the broad range of applications as we continue to search for meaningful and appropriate use of AI. AI literature in hip and knee arthroplasty between 2018 and 2021 regarding image-based analyses, value-based care, remote patient monitoring, and augmented reality was reviewed. Concerns surrounding meaningful use and appropriate methodological approaches of AI in joint arthroplasty research are summarized. Of the 233 AI-related orthopaedics articles published, 178 (76%) constituted original research, while the rest consisted of editorials or reviews. A total of 52% of original AI-related research concerns hip and knee arthroplasty (n = 92), and a narrative review is described. Three studies were externally validated. Pitfalls surrounding present-day research include conflating vernacular (“AI/machine learning”), repackaging limited registry data, prematurely releasing internally validated prediction models, appraising model architecture instead of inputted data, withholding code, and evaluating studies using antiquated regression-based guidelines. While AI has been applied to a variety of hip and knee arthroplasty applications with limited clinical impact, the future remains promising if the question is meaningful, the methodology is rigorous and transparent, the data are rich, and the model is externally validated. Simple checkpoints for meaningful AI adoption include ensuring applications focus on: administrative support over clinical evaluation and management; necessity of the advanced model; and the novelty of the question being answered.

Cite this article: Bone Joint J 2022;104-B(12):1292–1303.

Aims

This study describes the variation in the annual volumes of revision hip arthroplasty (RHA) undertaken by consultant surgeons nationally, and the rate of accrual of RHA and corresponding primary hip arthroplasty (PHA) volume for new consultants entering practice.

Balancing service provision and surgical training is a challenging issue that affects all healthcare systems. A multicentre prospective study of 1501 total hip replacements was undertaken to investigate whether there is an association between surgical outcome and the grade of the operating surgeon, and whether there is any difference in outcome if surgeons’ assistants assist with the operation, rather than orthopaedic trainees. The primary outcome measure was the change in the Oxford hip score (OHS) at five years. Secondary outcomes included the rate of revision and dislocation, operating time, and length of hospital stay. There was no significant difference in ΔOHS or complication rates between operations undertaken by trainers and trainees, or those at which surgeons’ assistants and trainees were the assistant. However, there was a significant difference in the duration of surgery, with a mean reduction of 28 minutes in those in which a surgeons’ assistant was the assistant. This study provides evidence that total hip replacements can be performed safely and effectively by appropriately trained surgeons in training, and that there are potential benefits of using surgeons’ assistants in orthopaedic surgery

Cadaveric specimens that have been fresh-frozen and then thawed for use have historically been considered to be the gold standard for biomechanical studies and the closest surrogate to living tissue. However, there are notable issues related to specimen rapid decay in the thawed state as well as infectious hazard to those handling the specimens. Cadaveric specimen preparation using a new phenol-based soft-embalmed method has shown considerable promise in preserving tissue in a prolonged fresh-like state while mitigating the infection risk. In this study, we evaluated the ability of soft-embalmed specimens to replace fresh-frozen specimens in the biomechanical study of flexor tendon repair. An ex-vivo study was conducted on six cadaveric hands in both a fresh-frozen, thawed state and following embalming with a phenol-based solution. Six different combinations of flexor digitorum profundus (FDP) tendons, from D2 to D5, and flexor pollicis longus (FPL) tendons were used to create two groups of similar composition with 15 tendons each, one group to be tested fresh and the other following embalming. A 5cm length of each flexor tendon was harvested from zone 2 and transversely cut at the mid-section. A modified-Kessler repair was performed on each specimen using 4–0 Fiberwire, with two core sutures and 1cm purchase on each end. Incisions were closed with a running stitch to prepare the specimen for embalming. The same protocol was used to repair and harvest the second group of tendons one month following the perfusion of a phenol-based solution through the vasculature of the hand and forearm. Tendon repair biomechanics were characterised through a ramp loading to failure (rate 1mm/sec), incorporating the 12 mm travel distance of the testing machine. A video-extensometry technique was used to validate machine recordings for the repair site for force at the 2mm gap distance, the ultimate strength, and the mode of failure. Characteristics of the two groups were tested for equivalency using inferential confidence intervals (ICI). Both fresh and embalmed groups were indistinguishable in both force at 2mm gap (fresh 17.9±4.7N; embalmed 18.1±5.1) and ultimate strength (fresh 43.93±10.0; embalmed 43.7±9.4). With the exception of one specimen with complete suture pull-out, all specimens exhibited partial pull-out as the final mode of failure. Our study demonstrated that tendon repair characteristics of phenol-embalmed specimens were equivalent to fresh specimens. Post-mortem chemical preservation can indeed preserve both visual and biomechanical characteristics of soft tissues. This study opens new avenues in support of the use of embalmed specimens in medical curricula and surgical training

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

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

Introduction. An emerging consensus in the surgical specialties is that skill acquisition should be more emphasized during surgical training. 1. This study was an attempt to evaluate the effects of repetitive practices using an image-free computer-assisted orthopaedic surgery (CAOS) guidance system (Exactech GPS, Blue-Ortho, Grenoble, FR) on both technical and cognitive skills. Materials and methods. A senior knee replacement surgeon with limited previous experience with the CAOS system performed a series of consecutive simulated knee surgeries using a commercially available artificial leg (MITA trainer leg M-00058, Medical Models, Bristol, UK). In order to assess the effects repetitive practice has on technical skills, we evaluated two indexes:. Error index: A unitless indication of overall error magnitude obtained by averaging the absolute values of all linear and angular measurement differences between targeted and checked cuts. Time index: An indication of the time required to acquire landmarks, adjust the custom blocks, and make cuts. In order to assess the effect repetitive practice has on cognitive skills, we evaluated the number of times the surgeon elected to deviate from pre-surgical planning or re-acquire landmarks. We evaluated these parameters for three chronological and consecutive groups of simulated surgeries: Group A (knee models #1 to #10), Group B (knee models #11 to #20), and Group C (knee models #21 to #28). Results. Regardless of the number of operations, tibial and femoral cuts were associated with a low error index (ranging from 0.45 to 0.71 for all three groups), suggesting the continuous guidance offered by the CAOS system provided an opportunity to correct discrepancies from the plan during surgery (Figure 1A). The variability of surgical time at key steps substantially reduced from Group A to Group C (Figure 1B). Finally, the surgeon elected to re-perform femoral landmark acquisitions 8 times for Group A, 4 times for Group B, and 0 times for Group C. Discussion. The authors attempted to delineate the effects of repetitive practices on skills using a CAOS system. The overall perception was the number of sequential practice surgeries had no significant effect on surgical accuracy. The significant decrease in the time index (43%) during the course of the practice surgeries is in line with recent studies regarding the learning curve associated with navigation for knee arthroplasty. 2. Compared to the initial planning, the only modifications in surgical steps were related to re-acquiring femoral landmarks. As with any image-free system, the present CAOS system relies on precise landmark acquisition. To achieve this goal, the system under consideration presents an interactive software enabling landmark visualization (Figure 2) allowing immediate feedback loop. Despite the obvious limitation of being conducted on synthetic bones, this study enabled a senior surgeon to perfect his technical and cognitive skills, potentially leading to increases in efficiency and efficacy in the intense environment of the operating room

Introduction. Entry into orthopaedic higher surgical training remains extremely competitive, however little evidence exists regarding the validity of short-listing and interviewing for selection. This paper assesses the relative correlations of short-listing and interview scores in predicting subsequent performance as an orthopaedic trainee. Methods. We compared data from the selection process (short-listing and interview scores) to subsequent performance during training (academic output and an annual assessment score by Programme Director). Data was prospectively collected from 115 trainees on the South West Thames region of the U.K. during 2000–2010. Results. We found that trainees achieving an interview score within the top third subsequently produced a higher academic output and had a higher annual assessment score than their peers (MANOVA, p>0.05) see Figure 1. [Academic output vs interview score rank (thirds)]. The short-listing scores did not correlate with subsequent academic output or annual assessment score see Figure 2. [Academic output vs shortlist score rank (thirds)]. We found no statistical correlation between the short-listing and interview scores (r. 2. < 0.1). Discussion. This study provides an evidence base to support the value of interviews by senior surgeons in the selection of trainees. We support the following selection process for orthopaedic trainees: long listing followed by a competitive interview(s) of all remaining candidates

Orthopaedics has been left behind in the worldwide drive towards diversity and inclusion. In the UK, only 7% of orthopaedic consultants are female. There is growing evidence that diversity increases innovation as well as patient outcomes. This paper has reviewed the literature to identify some of the common issues affecting female surgeons in orthopaedics, and ways in which we can address them: there is a wealth of evidence documenting the differences in the journey of men and women towards a consultant role. We also look at lessons learned from research in the business sector and the military. The ‘Hidden Curriculum’ is out of date and needs to enter the 21st century: microaggressions in the workplace must be challenged; we need to consider more flexible training options and support trainees who wish to become pregnant; mentors, both male and female, are imperative to provide support for trainees. The world has changed, and we need to consider how we can improve diversity to stay relevant and effective.

Cite this article: Bone Jt Open 2021;2-10:893–899.

Aims

Total hip arthroplasty (THA) is a very successful and cost-effective operation, yet debate continues about the optimum fixation philosophy in different age groups. The concept of the 'cementless paradox' and the UK 'Getting it Right First Time' initiative encourage increased use of cemented fixation due to purported lower revision rates, especially in elderly patients, and decreased cost.

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.

Competency levels of AOSpine members (Europe) based on whether or not they had undertaken a full 12 month fellowship in spinal surgery. Self-assessment questionnaire distributed to members (60 questions relating to: previous surgical training, fellowships and their nature, and both theoretical and practical competency amongst basic and advanced spinal conditions). 289 completed responses. Competency levels with(out) fellowship; differences in fellowship training; overall competence in spinal surgery as neurosurgeons versus those trained as orthopaedic surgeons. Competency defined as those able to deal with complications or able to perform without supervision. 28% (n=80) undertook a full 12 month fellowship. Notable differences between groups were identified (fellowship vs no fellowship): spinal deformity (58% vs 26%), cervical trauma (83% vs 59%), cervical stabilisation (78% vs 53%), lumbar and thoracic trauma (85% vs 57%) and anterior surgery (66% vs 41%) and its complications (46% vs 23%). Interestingly of the whole group only 43% were competent in the actual practice of conservative management of spinal conditions. There was no significant difference in theoretical knowledge or practical skills between orthopaedics surgeons and neurosurgeons. Fellowship training is effective, but there are deficiencies in areas. In order to provide a routine and emergency service as a spinal surgeon, competency at relatively common procedures must be reached. Our data demonstrates a lack of uniformity in such competencies, and we believe efforts towards a formal curriculum for spinal training should be embarked upon

Rheumatology and Musculoskeletal Sciences, NIHR Biomedical Research Unit, University of Oxford and the Nuffield Orthopaedic Hospital, Oxford. Purpose. The aim of this study was to use motion analysis to objectively study the learning curve of surgical trainees performing arthroscopic meniscal repair on a training model in a skills laboratory. Background. With improving technology and an appreciation of its likely chondroprotective effects, meniscal repair surgery is becoming more common. It remains a difficult procedure and is not routinely learnt during surgical training. Methodology. 19 orthopaedic surgical trainees watched an instructional video of a meniscal repair method (Smith & Nephew Fast-Fix) and then performed 12 meniscal repair episodes on a ‘sawbones’ knee simulator with a standardised lateral meniscal tear. The 12 repair episodes were performed during over a 3 week period. A validated motion analysis system was used to record: distance travelled by each hand; number of hand movements; and time taken to complete the task. Results. Time taken, number of hand movements and total path travelled all showed improvements over the twelve episodes. Time taken improved by 34%, Total path travelled by 21%, and Hand movements improved by 27% for the camera hand (right) and 19% for the instrument hand (left). There was evidence of plateau on the learning curve over the 12 episodes, with larger improvements in measured outcomes over the initial episodes compared to the last episodes. Conclusion. This study objectively demonstrates a learning curve for surgeons performing arthroscopic meniscal repair in a skills laboratory. It indicates the benefits to surgical trainees of practicing such arthroscopic techniques in a skills centre prior to progressing to the operating theatre

Introduction. The aim of the study was to compare and contrast the clinical outcome of conversion of practice of a shoulder surgeon from open to arthroscopic shoulder stabilisation for traumatic anterior shoulder instability. Patients and Methods. Comparison of a cohort consecutive series of 24 patients treated by open stabilisation and a prospective consecutive cohort series of 30 patients treated by arthroscopic stabilisation. Clinical outcomes were assessed with Oxford Shoulder Score Instability (OSS-I) and a Patient Satisfaction Survey at a minimum of 1 year follow up. The operation time as well as cost analysis were also evaluated. Results. The average OSS-I for open stabilisation was 39.6 (range 19-48) as compared to 39.8 (range 23-48) with the arthroscopic group and these scores did not show a statistically significant difference. Both cohorts were pleased with the clinical outcome and were happy to recommend the procedure to others. No complications in either group were seen. Operative time and costs were significantly more in the open group, even taking into account initial learning curve of the arthroscopic method. All arthroscopic procedures were performed as day-cases compared to over-night stays for the open group also providing better use of hospital resources and cost savings. Conclusion. After appropriate surgical training, the conversion from open to arthroscopic stabilisation can be performed without affecting clinical outcome or patient satisfaction. This study provides surgeons with confidence to change methods to gain the advantages of the arthroscopic procedure, which included reduced theatre time, day case surgery and earlier return to work and sport

Introduction. Architectural changes occurring in the proximal femur after THA continues to be a problem. Stress shielding occurs regardless of fixation method. The resultant bone loss can lead to implant loosening and breakage of the implant. A new novel tissue sparing neck-stabilised stem has been designed to address these concerns. Methods. Over 1,200 stems have been implanted since April 2010 and 2012. Patient profile showed two-thirds being female with an age range between 17 to early 90s. 90% were treated for OA. This stem has been used in all Dorr bone classification (A, B, & C). Two surgical approaches were utilised (single anterior incision and standard posterior incision). All were used with a variety of cementless acetabular components and a variety of bearing surfaces (CoC, CoP, MoM, MoP). Complications were track by surgeon Members of the Tissue Sparing Study Group of the Joint Implant Surgery and Research Foundation. Complications include first year of limited clinical release. No surgeon was permitted usage without specific cadaver / surgical training. No head diameters below 32 mm were used. Observations. There is a short but definitive learning curve (2–3 cases) and an easy transition for the O.R. team due to the limited inventory of stem sizes. The three main surgical technique features are: Level of neck resection, angle of resection and rasping the proximal medial curvature of the femur. Stem usage: size 0, 1 and 2 were used for more females and 3, 4, and 5 stems for males. The neutral modular neck was the single most selected (35%), however, all angled necks totaled 65% usage. Slightly more complications in the anterior approach compared to posterior approach. We are encouraged with our initial clinical / surgical / radiographic observations and believe our results warrant not only further evaluation but expanded evaluation of this tissue conserving approach to THA

The Accreditation Council of Graduate Medical Education (ACGME) has formalized a limit of 16 consecutive duty hours for first year and 20 hours for intermediate level trainees, while maintaining a maximum of 80 duty hours per week despite social pressure to further reduce this limit. Deterioration in cognitive and technical performance secondary to fatigue is the basis for the 16 hour rule, along with the notion that “strategic napping” be strongly encouraged for trainees that must remain for longer shifts. For more senior trainees, graduated independence and responsibility are recognized as important to prepare for the independent practice of medicine. Yet, a reduction of nearly 7000 hours, or the equivalent of 2 years of surgical education and experience, results from the 80-hour duty limitation compared to surgical training of two decades ago. The contention is that duty hours must be constrained to optimize patient safety and the learning environment, but it is unclear whether mastery of the necessary cognitive and technical competencies can be achieved in such a constricted time period. Another worrisome by-product of legislated duty hour limitations is the unintended encouragement of a “shift worker” mentality and erosion of the ethos of professionalism among trainees. Effective mentoring takes on critical importance in this challenging environment, yet productive mentoring may be counter to learned adaptive behaviours and instinctive personality traits of some accomplished surgeon educators. Fostering effective mentors in academic surgery requires us to develop behaviors that are conducive to the mentoring process. As our trainees struggle to achieve mastery of a surgical discipline within a prescribed and constricted time period, we must consider a competency-based system of surgical education rather than one that is time-defined. Likewise, the personal and professional growth of our trainees in this system, as well as the succession planning for our specialty, are dependent upon the creation of an environment conducive to effective mentoring in academic orthopaedics

Introduction and Aims: Much of the world faces life without affordable health care. The burden of affordable specialist care has fallen, in large part, on visiting medical volunteers. However, culturally and resource-appropriate patient care is possible. Surgical specialties such as orthopaedic surgery can be developed by providing seed knowledge and skill and developing indigenous skills. Method: This presentation is based on personal experience in developing countries, specifically the Sihanouk Hospital Centre of HOPE. Results: Surgical and orthopaedic training has been developed in this resource-poor environment and the individual challenges have been met. A graduate approach to instruction and training is needed and this takes longer than would be the case in a more developed setting. Conclusion: Surgical training programs, which respect local attitudes and culture, can be set up in resource-poor settings

Introduction. Restrictions placed on the working hours of doctors have led to increasing time-pressures on surgical training. Consequently, there has been growing interest in developing new techniques to teach and assess technical skills. The primary aim of this study was to determine whether a novel set of visual parameters assessing visuospatial ability, fine motor dexterity and gaze control could objectively distinguish between varying levels of arthroscopic experience. The secondary aim was to evaluate the correlations between these new parameters and previously established technical skill assessment methods. Methods. 27 subjects were divided into a “novice” group (n=7), “trainee” group (n=15) and expert group (n=5) based on previous arthroscopic experience. All subjects performed a diagnostic knee arthroscopy task on a simulator. Their performance was assessed using new simple visual parameters that included “prevalence of instrument loss,” “triangulation time” and “prevalence of look downs”. In addition, performance was also evaluated using previously validated technical skill assessment methods (a global rating scale and motion analysis). Results. A significant difference in performance between the groups was demonstrated using all three novel visual parameters, the global rating scale and motion analysis (Mann-Whitney U test, p< 0.05). There were strong and highly significant correlations (Spearman's rank correlation coefficient, p< 0.0001) between each of the novel parameters and the previously validated skill assessment methods. Conclusion. This study demonstrates the construct validity of three novel visual parameters for objectively assessing arthroscopic performance. Two of these are simple, can be used easily in the operating theatre, and are highly correlated with current validated methods of technical skill assessment. Given the paramount importance of identifying objective methods for evaluating technical skill in arthroscopic surgery, the generic nature of these simple visual parameters make them a powerful and user-friendly objective assessment tool, which may offer an alternative to existing assessment methods

With the imminent introduction of the Modernising Medical Careers (MMC) post-graduate training programme, we undertook a study to assess how informed the orthopaedic Multi Disciplinary Team (MDT) and patients were with regard to the details, implementation and future implications of MMC. Methods: A questionnaire was designed to record the level of awareness of MMC using a visual analogue scale and to document individual preferences for surgical training, either traditional or MMC. 143 questionnaires were completed – consultant orthopaedic surgeons (n=12); orthopaedic nursing staff (n=54); musculoskeletal physiotherapists (n=27); and trauma and orthopaedic patients (n=50). Results: Consultants felt most informed about MMC compared to patients and other members of the multidisciplinary team (p < 0.01). Consultants preferred old style training in terms of their juniors as well as future consultant colleagues. Nurses showed no preference for either system. Patients and physiotherapists expressed a preference for their surgeon to have been trained under the traditional, rather than the new system. Conclusions: Our study showed that there is a wide variation in the degree to which patients and healthcare professionals are informed about MMC

Purpose: The development of confidence in the operating room is a major goal of surgical training. Confidence in surgery involves trusting information, intuition and experience. Confidence can also be detrimental when it impedes the ability to self-assess skills and decision-making. The measurement of confidence is difficult owing to the sequential acquisition of information and experience. The following study examines the trends in self-reported confidence in residents participating in cadaveric arthroscopic courses. Method: In 2007 and 2008 residents participating in annual arthroscopic courses at the returned pre-course and post-course questionnaires recording previous arthroscopic exposure. Participants had access to fresh-frozen cadaver specimens and arthroscopic instruments for five hours after didactic lectures. Each participant rated perceived confidence and skill on a five-point Likert scale before and after the course. Mean confidence was compared using a student’s t-test. Data were further analysed using linear regression of pre – and post-course Likert scores. Results: Residents showed a significant increase in self-perceived confidence in the performance of meniscal repair, anterior cruciate ligament reconstruction and labral repair and subacromial decompression directly after an arthroscopy course (p< 0.01). Regression analysis yielded a y-intercept not significantly different from zero prior to the course with a significant increase in the intercept after the course. There was no significant difference in the relationship of increasing arthroscopic experience to training noted as a result of the course. Conclusion: Novice residents appeared to gain more self-reported confidence than experienced residents following an arthroscopic skills course. Future courses should consider the separation of novice and experienced residents to focus on improving the self-perceived confidence of experienced residents while exposing novice residents to the complexities of arthroscopic techniques. More research is needed to increase the understanding of the effects of confidence on trainees at various stages of training

Background. Surgical simulators allow learner-focussed skills training, in controllable and reproducible environments suitable for assessment. Aim. To research the face validity (extent to which the simulator resembles reality, determined subjectively by subjects), and construct validity, (ability to objectively differentiate between subjects with varying levels of arthroscopic experience) of a virtual reality arthroscopy simulator, to validate its effectiveness as an educational tool. Methods. Using the simulator insightArthroVR®, 37 subjects were required to perform diagnostic knee arthroscopy, palpate anatomical landmarks and complete questionnaires. The simulator recorded objective data to assess proficiency: time to complete tasks, roughness in instrument handling, and path length covered by the arthroscope and palpation probe. Results. The simulator succeeded in proving face validity: 86.4% participants agreed the simulator provided insight into arthroscopy. Training met the expectations of 91.3% and showed improvement in novices in simulated diagnostic arthroscopy in completion time (p-value=0.036), roughness (p-value=0.026), and path length covered by the arthroscope (p-value=0.008). Furthermore, the simulator was able to discriminate between experts, intermediates and novices, proving construct validity: time of completion (p-value=0.009), the path length covered by the arthroscope (p-value=0.02) and the probe (p-value=0.028). Conclusions. Results demonstrate the simulator succeeds in emulating real arthroscopy and can discriminate between subjects according to arthroscopic experience, proving face and construct validity. Further research on transfer of skills to the operating room needs to be done. With surgery constantly modernising and increasing time constraints with the EWTD, training must be efficient and assessable without compromising patient safety. Simulators could allow trainees earlier exposure to procedures, a wider range of pathologies in a compressed period, practice outside the OR, and an acceleration of the learning curve. This study has taken a step forward in validating a VR simulator and thus a step towards the future of simulation becoming an indispensable adjunct to surgical training

Anecdotal concern exists over the ability of current UK trainees to manage complex orthopaedic trauma. A 15 item web-based survey sent to a sample of orthopaedic trainees. Power calculations deemed 222 responses from 888 trainees necessary to achieve a 5% error rate with 90% confidence limits. 232 responses were received. For cases involving external fixation or intramedullary nailing, perceived confidence and training adequacy was high despite infrequent exposure. Perceived confidence and adequacy of training in complex trauma is significantly lower. Less than 20% of trainees have full confidence in their ability to debride and stabilize mutilating hand injuries. 35% of trainees lack confidence in their assessment of limb viability and 56% lack confidence in amputation for extremity trauma. 71% of trainees are not confident in the management of junctional trauma and 68% regard their training in this field as inadequate. With regard to advanced resuscitation using novel blood product combinations; 65% of trainees are lacking confidence and 44% perceive their training as inadequate. For simple fracture stabilisation, vacuum dressings, antibiotic pro-phylaxis and fasciotomy, trainee perceived confidence increased with time in training. This increase did not occur in more complex trauma cases. Perceived confidence amongst orthopaedic trainees in the management of routine extremity trauma is high despite limited exposure and concerns over changes in surgical training. This is in marked contrast to that reported in complex trauma. For military trainees, the value of supervised training on military deployment to gain experience in such cases is now apparent

Podiatrists have an important role in providing care in a Foot and Ankle clinic. Most Foot and Ankle Surgeons welcome the assistance they can provide – in a supervised role. Most Trusts should have one Foot and Ankle Surgeon but there are a limited number of trained specialists. Some Trusts have been appointing ‘Consultant Podiatric Surgeons’ – perhaps as a way of addressing this shortfall. There are potentially a number of concerns amongst Foot and Ankle Surgeons: the public perception of title ‘consultant’; a Non supervised role; Potential to be used as a more cost effective option. We therefore undertook a Questionnaire assessment of patients attending a Foot and Ankle Clinic. Over a six week period 148 patients attended the specialist clinic. Of those 76% responded. 64% were females. The average age range was 45-64. Most patients assumed the Consultant in charge of their care was a qualified medical practitioner (93%) and regulated by the GMC (92%) and who had completed a recognised higher surgical training scheme (93%). Irrespective of suitable experience 2 out of 3 patients stated they would object if the Consultant in charge of their care did not meet the above criteria. If the patient required surgery 80% stated they would object if the supervising Consultant was not a medically qualified doctor (this was more important in female patients) Interestingly 78% stated they would refuse surgery unless they were under the care of a medically qualified doctor. Very few patients understood the title Consultant Podiatric Surgeon (with those responding assuming they were medical doctors). This potentially has significant implications in those Trusts employing Consultant Podiatric Surgeons as opposed to Foot and Ankle (Orthopaedic) Surgeons. Unless this differential is clearly explained to the patients there is an issue with informed consent and the potential for litigation

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

The amount of time spent in theatre by trainees is decreasing and therefore it seems crucial to fully optimis e these to enable adequate training. Trainees at the beginning of their practice, despite their exposure to surgery, cannot always take advantages of the surgical procedure they are assisting with. An obvious example of this is total hip replacement during posterior approach. Although the posterior approach and less invasive or minimally invasive approaches are certainly beneficial for patients, they are very difficult for a young trainee to comprehend, as they spend most of the time hanging onto the retractor without or rarely seeing the important anatomic steps of the procedure. Our goal was to develop a tool that would help a trainee to fully see and understand the surgical steps of total hip replacement during a posterior approach. To enable visualisation of the operation from the senior surgeon's perspective we developed a device to film the surgery and output the video feed to a screen. The prototype used an HD Replay XD1080 camera connected to a WDHI Xenta transmitting dongle (transmitting frequency −5.8 GHz), with an onboard 6600 mAh external Li-Mh battery providing 1A of current to the system. The Replay camera was fixed to the surgeon's ventilation helmet, and took its power from the battery supplying both the fan system and the transmitting unit. The surgeon can then clip both of these items to his belt and the connecting wires and cables run up his back. The device provided a Full HD video output of the surgery from the surgeon's perspective. The receiving unit used a Xenta WHDI wireless receiver with HDMI and DVI-I/D connections allowing the video to be displayed on any screen in the operating room with these connections. The prototype has been trialled by the senior author and was successful in allowing the direct surgeon's view of the procedure to be displayed on a screen in the theatre so that other staff involved in the operation could see it. Although the use of virtual training, presentations and video are essential to training, surgical training still relies greatly upon surgical assistance. The introduction of an intra-operative video feedback device would enable trainees to observe the operation from a first-person perspective which could lead to a considerable reduction in the amount of training time required, as well as a better understand of the specific surgical steps in a procedure. This would be particularly use for operations where a trainee assists the surgeon from the opposite side of the operating table, for example when undergoing total hip replacement during posterior approach. We can also envision this device also being used by surgeons to monitor their trainees when operating, and perhaps to keep a record of the operations undertaken in an establishment for archiving or assessment

Aim: To establish confidence and perceived adequacy of training of UK Orthopaedic Specialist Trainees in assessment of limb viability and amputation. Methods: A web based survey of orthopaedic trainees using scenarios centred around limb viability assessment and amputation resultant from trauma. 225 responses obtained, achieving a < 0.05 error rate with 90% confidence. Results:. Limb viability:. 27.8% were fully confident. A positive correlation exists between training year and fully confident reports. 68.6% encounter such injury either every six months or less frequently. 18.6% regard their training in these cases inadequate. No correlation seen between experience and perceived adequacy of training. Amputation:. 10.3% were fully confident. A positive correlation exists between time in training and perceived fully confident reports. 57.3% encounter such injury either every six months or less frequently. 36.3% regard their training in these cases inadequate. No correlation seen between experience and exposure to cases or perceived adequacy of training. Conclusion: Current training provides limited opportunities for decision making in limb viability and amputation. Confidence in dealing with such cases is seen to increase with training. Perceived adequacy of training did not change over time. Military orthopaedic surgeons are providing injured service personnel and civilians with the best possible chance of successful rehabilitation from these injuries. It is fundamental that the experience of these individuals is accessible to their successors. For military trainees, this reinforces the need for participation in closely supervised secondments on deployment, attendance at established military surgical training courses and appropriate fellowships to maximise exposure prior to completion of training and first consultant deployment

Aim: Our aim was to find the effect of implementation of European working time directive (EWTD) on current Orthopaedic training in England. Hip fracture surgery is one of the most frequently performed operation on the trauma lists and hence it is considered mandatory to independently able to perform hip fracture surgery in the registrar training curriculum. Methods: This reaudit was performed over four month period in 2007 (1st April to 31st July) collating information on 1010 hip fracture patients undergoing surgery in 14 NHS hospitals in the North Western deanery of England. Results: An orthopaedic trainee of registrar level (Speciality trainee year 3–6) was the lead surgeon in 37% of cases while only 4% of operations were performed by a Speciality trainee year 1–2 or Foundation year 2 (senior house officer grade) in 2007. These findings varied amongst the audited hospitals but in one hospital, trainees operated on only 12% of hip fractures. In previous audits done in 2003 and 2005, Orthopaedic registrar’s operated on 52 % and 50% of hip fractures respectively. Similarily senior house officers had hands on experience on 11% and 9% of hip fractures in 2003 and 2005 respectively. Discussion: European working time directive has reduced the working hours, leading to decreased hours of surgical training. The Orthopaedic Competence Assessment Project (OCAP) and the Intercollegiate Surgical Curriculum Project (ISCP) expects trainees to achieve core competencies in key procedures such as hip fracture surgery. In the context of shorter training and reduced working hours, to achieve these core competencies it is imperative to maximise operative exposure and experience for trainees. If the findings of this reaudit in Northwest of England are mirrored elsewhere in United Kingdom, the implications for orthopaedic training are significant

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

Surgical training in the UK since the Second World War has developed into a world class education programme. However, with the dramatic increase in the number of doctors and surgeons, combined with the improvement in access to health care, pathologies are now being treated earlier, and trainee exposure to advanced pathology has consequentially reduced. Not all countries are as privileged as the UK to have 3 doctors per 1000 head of population; South Africa has approximately 1/3rd of this number, Cambodia 1/10. th. , and Malawi 1/100. th. Many of these countries have difficulty filling posts for medical professionals within their own hospitals. The publication of the CRISP report and Lord Crisp's subsequent book ‘Turning the world upside down’ in 2010, highlighted, and tried to produce evidence of the mutual benefit of international health links to both the developed and the developing countries. It cited the bilateral transfer of skills and ideas, development of management skills, and improved workforce morale as beneficial effects of such links. The Department for International Development has prioritised the formation of these international partnerships. The Tropical Health Education Trust has been given the task of distributing grant funds. There are over 100 currently established and funded different health links across the UK. Some local links already exist such as the Gloucester NHS Trust Kambia, Sierra Leone link which focuses on maternal health, NHS South Centrals leadership programme which has a broader remit and works in conjunction with the ministries of health in certain areas of Tanzania and Cambodia and UHB/BRI link with Mbarara, Uganda in obstetrics, child health, ophthalmology. Over the last 4 years, a series of South West Trainees have spent 1 year working in hospitals in Malawi and South Africa. The positive feedback that they have given, the dramatic increase in the surgical exposure as documented in their log books, and the number of high quality research projects that they have published as a result, has led to the programme director looking favourably on future requests. We feel it would be mutually beneficial to formalise these links, with a regular stream of surgeons from this region spending time in these hospitals. Benefits for the recipient hospital would be a dependable and regular supply of staff, who could be incorporated into more long scale programmes, aimed at improving regional health care. Benefits to the donor institution and surgeon would be streamlined application process, simpler living logistics, car house etc, continuity of research projects, and the possibility to apply for funding for local research staff

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