Matthew D. Karam

Current and Future Use of Surgical Skills Training Laboratories in Orthopaedic Resident Education: A National Survey

BACKGROUND Acquisition of surgical skills through laboratory-based training and simulation is appealing to surgical training programs. The purpose of this study was to provide baseline information on the current use of surgical skills training laboratories in orthopaedic resident education and to determine the interest in expansion of these facilities and training techniques. METHODS The creation of the survey was a collaborative effort between the authors and the American Academy of Orthopaedic Surgeons (AAOS). Two online versions of the Surgical Skills Simulation survey were created, one (with twenty-three items) specifically for program directors and one (with fourteen items) for orthopaedic residents. The survey was sent via e-mail to 185 program directors and 4549 residents. Data were retrieved and analyzed by the AAOS Department of Research and Scientific Affairs. RESULTS Eighty-six (46%) of the 185 surveys distributed to orthopaedic surgery residency directors and 687 (15%) of the 4549 distributed to orthopaedic surgery residents were completed. Seventy-six percent of the program directors reported having a surgical skills laboratory, and 46% of these reported having a structured surgical skills laboratory curriculum. Fifty-eight percent of program directors and 83% of residents believed that surgical skill improvement by orthopaedic residents was not being objectively measured. Both 80% of program directors and 86% of residents agreed that surgical skills simulations should become a required part of training, and 82% and 76% were interested in a standardized surgical skills curriculum. Eighty-seven percent of program directors identified a lack of available funding as the most substantial barrier to development of a formal surgical skills program at their institution. CONCLUSIONS There was strong agreement among both program directors and residents that surgical skills laboratories and simulation technology should be a required component of orthopaedic resident training. At the present time, the most substantial barrier to adoption of surgical skills laboratories and a formalized surgical skills curriculum is the lack of funding.

Objective Structured Assessments of Technical Skills (OSATS) Does Not Assess the Quality of the Surgical Result Effectively

BackgroundPerformance assessment in skills training is ideally based on objective, reliable, and clinically relevant indicators of success. The Objective Structured Assessment of Technical Skill (OSATS) is a reliable and valid tool that has been increasingly used in orthopaedic skills training. It uses a global rating approach to structure expert evaluation of technical skills with the experts working from a list of operative competencies that are each rated on a 5-point Likert scale anchored by behavioral descriptors. Given the observational nature of its scoring, the OSATS might not effectively assess the quality of surgical results.Questions/purposes(1) Does OSATS scoring in an intraarticular fracture reduction training exercise correlate with the quality of the reduction? (2) Does OSATS scoring in a cadaveric extraarticular fracture fixation exercise correlate with the mechanical integrity of the fixation?MethodsOrthopaedic residents at the University of Iowa (six postgraduate year [PGY]-1s) and at the University of Minnesota (seven PGY-1s and eight PGY-2s) undertook a skills training exercise that involved reducing a simulated intraarticular fracture under fluoroscopic guidance. Iowa residents participated three times during 1 month, and Minnesota residents participated twice with 1 month between their two sessions. A fellowship-trained orthopaedic traumatologist rated each performance using a modified OSATS scoring scheme. The quality of the articular reduction obtained was then directly measured. Regression analysis was performed between OSATS scores and two metrics of articular reduction quality: articular surface deviation and estimated contact stress. Another skills training exercise involved fixing a simulated distal radius fracture in a cadaveric specimen. Thirty residents, distributed across four PGY classes (PGY-2 and PGY-3, n = 8 each; PGY-4 and PGY-5, n = 7 each), simultaneously completed the exercise at individual stations. One of three faculty hand surgeons independently scored each performance using a validated OSATS scoring system. The mechanical integrity of each fixation construct was then assessed in a materials testing machine. Regression analysis was performed between OSATS scores and two metrics of fixation integrity: stiffness and failure load.ResultsIn the intraarticular fracture model, OSATS scores did not correlate with articular reduction quality (maximum surface deviations: R = 0.17, p = 0.25; maximum contact stress: R = 0.22, p = 0.13). Similarly in the cadaveric extraarticular fracture model, OSATS scores did not correlate with the integrity of the mechanical fixation (stiffness: R = 0.10, p = 0.60; failure load: R = 0.30, p = 0.10).ConclusionsOSATS scoring methods do not effectively assess the quality of the surgical result. Efforts must be made to incorporate assessment metrics that reflect the quality of the surgical result.Clinical RelevanceNew objective, reliable, and clinically relevant measures of the quality of the surgical result obtained by a trainee are urgently needed. For intraarticular fracture reduction and extraarticular fracture fixation, direct physical measurement of reduction quality and of mechanical integrity of fixation, respectively, meet this need.

Does a Trauma Course Improve Resident Performance on the Trauma Domain of the OITE

BACKGROUND Lecture-based courses are common in orthopaedic surgery; however, their effectiveness in improving medical knowledge has not been widely assessed. The Orthopaedic Trauma Association conducts a resident trauma course that occurs four to six weeks prior to the Orthopaedic In-Training Examination (OITE). The purposes of this study were to determine whether residents who had taken this course performed better on the trauma domain of the OITE and to compare the effect of the course with the effect of a focused rotation in orthopaedic trauma. METHODS The percentile scores on the trauma domain of the OITE for forty-seven residents in postgraduate year (PGY) 2 were reviewed. Twenty-nine residents who took a trauma course within six weeks before the OITE were compared with eighteen residents who took the course after the OITE. As a secondary analysis, the effect of a trauma rotation for the same PGY-2 residents before and after the OITE was also assessed. Baseline orthopaedic knowledge was assessed with use of the overall OITE percentage scores. RESULTS The trauma domain scores were not significantly better among the residents who took the course (mean and standard deviation, 62.2 ± 9.9) compared with those who had not taken it (mean, 59.2 ± 6.2) (p = 0.2). A significant difference (p = 0.04) was found for a trauma rotation, with the residents who had a trauma rotation scoring better (mean, 64.5 ± 6.8) than the residents who had not (mean, 58.8 ± 8.9). The subgroup of residents who had both a course and a trauma rotation before the test scored significantly better (p = 0.01) than the subgroup that had neither of these experiences before the test (mean, 65.6 ± 8.0 and 56.9 ± 6.4, respectively). CONCLUSIONS An orthopaedic trauma course alone does not enhance an orthopaedic residents trauma medical knowledge as assessed on a standardized test. However, a trauma rotation before, and in particular the combination of both a course and a trauma rotation, can improve trauma test scores.

Building a clinical research network in trauma orthopaedics: The major extremity trauma research consortium (METRC)

Objectives: Lessons learned from battle have been fundamental to advancing the care of injuries that occur in civilian life. Equally important is the need to further refine these advances in civilian practice, so they are available during future conflicts. The Major Extremity Trauma Research Consortium (METRC) was established to address these needs. Methods: METRC is a network of 22 core level I civilian trauma centers and 4 core military treatment centers—with the ability to expand patient recruitment to more than 30 additional satellite trauma centers for the purpose of conducting multicenter research studies relevant to the treatment and outcomes of orthopaedic trauma sustained in the military. Early measures of success of the Consortium pertain to building of an infrastructure to support the network, managing the regulatory process, and enrolling and following patients in multiple studies. Results: METRC has been successful in maintaining the engagement of several leading, high volume, level I trauma centers that form the core of METRC; together they operatively manage 15,432 major fractures annually. METRC is currently funded to conduct 18 prospective studies that address 6 priority areas. The design and implementation of these studies are managed through a single coordinating center. As of December 1, 2015, a total of 4560 participants have been enrolled. Conclusions: Success of METRC to date confirms the potential for civilian and military trauma centers to collaborate on critical research issues and leverage the strength that comes from engaging patients and providers from across multiple centers.

A simulation trainer for complex articular fracture surgery.

BACKGROUND The purposes of this study were (1) to develop a physical model to improve articular fracture reduction skills, (2) to develop objective assessment methods to evaluate these skills, and (3) to assess the construct validity of the simulation. METHODS A surgical simulation was staged utilizing surrogate tibial plafond fractures. Multiple three-segment radio-opacified polyurethane foam fracture models were produced from the same mold, ensuring uniform surgical complexity between trials. Using fluoroscopic guidance, five senior and seven junior orthopaedic residents reduced the fracture through a limited anterior window. The residents were assessed on the basis of time to completion, hand movements (tracked with use of a motion capture system), and quality of the obtained reduction. RESULTS All but three of the residents successfully reduced and fixed the fracture fragments (one senior resident and two junior residents completed the reduction but were unsuccessful in fixating all fragments). Senior residents had an average time to completion of 13.43 minutes, an average gross articular step-off of 3.00 mm, discrete hand motions of 540 actions, and a cumulative hand motion distance of 79 m. Junior residents had an average time to completion of 14.75 minutes, an average gross articular step-off of 3.09 mm, discrete hand motions of 511 actions, and a cumulative hand motion distance of 390 m. CONCLUSIONS The large difference in cumulative hand motion distance, despite comparable numbers of discrete hand motion events, indicates that senior residents were more precise in their hand motions. The present experiment establishes the basic construct validity of the simulation trainer. Further studies are required to demonstrate that this laboratory-based model for articular fracture reduction training, along with an objective assessment of performance, can be used to improve resident surgical skills.

An Evaluation of the Ota-ofc System in Clinical Practice: A Multi-center Study With 90 Days Outcomes

Objectives: The purpose of this study is to evaluate the predictive ability of the Orthopedic Trauma-Open Fracture Classification (OTA-OFC) system in regards to short-term (90 days) outcomes of amputation, infection necessitating intravenous antibiotics, and wound healing in clinical practice across multiple centers. Design: Prospective observational study. Setting: Academic and private practice. Patients/Participants: Patients with open fractures. Intervention: None. Main Outcome Measurements: OTA-OFC, amputations, IV antibiotics, and wound healing. Results: Three hundred seventy-three patients with a total of 419 open fractures were enrolled. Logistic regression to predict amputation demonstrated that arterial and skin injury were statistically significant contributors to the prediction of amputation. Bone loss and muscle injury were significant contributors to the prediction of readmission for IV antibiotics. None of the variables in the OTA-OFC were significant predictors of unhealed wounds. Conclusion: Our study demonstrates the predictive value of the OTA-OFC regarding the short-term (90 days) outcomes of amputation and infection necessitating IV antibiotics and is another step towards the validation of the OTA-OFC in widespread clinical practice. Level of Evidence: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Percutaneous Reduction and Screw Fixation of Displaced Intra-articular Fractures of the Calcaneus:

Background: Extensile open approaches to reduce and fix intra-articular calcaneal fractures are associated with high levels of wound complications. To avoid these complications, a technique of percutaneous reduction and fixation with screws alone was developed. This study assessed the clinical outcomes, radiographs, and postoperative CT scans after operative treatment with this technique. Methods: 153 consecutive patients with 182 intra-articular calcaneal fractures were reviewed. All patients were assessed for early postoperative complications at 3 months from the injury. The clinical results were assessed for patients seen at a minimum of 1 year after surgery (mean follow-up of 2.6 years; 90 patients, 106 feet). In patients who had both preoperative and postoperative CT scans (50 patients, 60 feet), the articular reduction was quantitatively analyzed. Results: At the 3-month follow-up, there were 1% superficial infections and 1% rate of screw irritation. The complications at a minimum of 1 year after injury included screw irritation 9.3%, subtalar osteoarthritis requiring subtalar fusion 5.5%, malunion 1.8%, and deep infection 0.9%. Bohler angle, calcaneal facet height, and width were significantly improved postoperatively (P < .01). Bohler angle increased on average +24.1 degrees postoperatively with a loss of angle of 4.9 degrees at the 3-month follow-up. There was significant improvement (P < .01) in posterior talocalcaneal joint reduction on postoperative CT scan but residual displacement remained. At the final follow-up, 54.5% of the patients reported a residual pain level of 3 or lower. Conclusion: This study suggests that reasonable early results could be achieved from the percutaneous treatment of intra-articular calcaneal fractures using screws alone based on articular reduction and level of residual pain. Level of Evidence: Level IV, retrospective case series.

The Cost of Getting Into Orthopedic Residency: Analysis of Applicant Demographics, Expenditures, and the Value of Away Rotations.

OBJECTIVES Little is known about the demographics and expenditures of applicants attempting to match into the competitive field of orthopedic surgery. In attempt to better inform potential applicants, the purposes of this work are to (1) better understand the demographics of successfully matched applicants, (2) determine the monetary cost of applying, and (3) assess the value of away rotations for improving chances of a successful match. DESIGN Prospective comparative survey. SETTING Mayo Clinic Department of Orthopedic Surgery, Rochester, MN. PARTICIPANTS A week following the 2015 Orthopedic Surgery Residency Match, a survey was sent to 1,091. The survey focused on applicant demographics, number of programs applied to, cost of applying, and the value of away rotations. RESULTS A total of 408 applicants completed the survey (response rate = 37%). Of these, 312 (76%) matched and 96 (24%) did not match into a US Orthopedic Surgery Residency. Of the matched applicants, 300 (96%) were from US allopathic medical schools, 9 (3%) US Osteopathic Schools, and 3 (1%) were international graduates. Males comprised 84% of these applicants whereas 16% were female. The mean number of programs applied to was 71 (range: 20-140). On average, applicants were offered 16 interviews (range: 1-53) and they attended 11 (range: 0-12). Completing a rotation at a program increased an applicant׳s chances of matching into that program by a factor of 1.5 (60% vs 40%). Of the applicants who matched, most applicants matched to an orthopedic residency in the same region where the applicant attended medical school (58%). The average cost of the application was

There is poor reliability of Böhler's angle and the crucial angle of Gissane in assessing displaced intra-articular calcaneal fractures.

1,664 (range:

A Surgical Skills Training Curriculum for Pgy-1 Residents: Aaos Exhibit Selection

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