This work demonstrates a novel augmented reality simulation of guide-wire insertion in DHS surgery. To our knowledge this has not been previously achieved. In contrast to virtual reality, augmented reality is able to simulate fluoroscopy while allowing the trainee to interact with real instrumentation and performing the procedure on workshop bone models.

Background: FluoroSim, a novel fluoroscopic simulator, can be used to practice dynamic hip screw (DHS) guidewire insertion in a high-fidelity clinical scenario. Our aim was to demonstrate a training effect in undergraduate medical students who are not familiar with this operation and its simulation. Methods: Forty-five undergraduate medical students were recruited and randomized to either training (n = 23) or control (n = 22) cohorts. The training cohort had more exposure to FluoroSim (5 attempts each week) over a 2-week period (with a 1-week washout period in between) compared with the control cohort (a single attempt 1 week apart) over a 2-week period. Five real-time objective performance metrics were recorded: (1) tip-apex distance (TAD) (mm), (2) predicted cut-out rate (%), (3) total procedural time (sec), (4) total number of radiographs (n), and (5) total number of guidewire retries (n). Results: At baseline, there was no significant difference in the performance metrics, which confirmed the absence of a selection bias. The intragroup training effect demonstrated a significant improvement in all metrics for the training cohort only. A significant difference between groups was demonstrated as the training cohort significantly outperformed the control cohort in 3 metrics (procedural time [25%], number of radiographs [57%], and number of guidewire retries [100%]; p < 0.001). A learning curve showed an inversely proportional correlation between frequency of attempts and procedural time as well as the number of digital fluoroscopic radiographs that were made, indicating the development of psychomotor skills. There was also an improved baseline of the learning curve after the 1-week washout period, suggesting skill retention. Conclusions: Skill acquisition with the FluoroSim system was demonstrated with repeat exposure in a safe, radiation-free high-fidelity clinical simulation with actual operating room equipment. The task of DHS guidewire insertion requires cognitive and psychomotor skills that take a variable number of attempts to acquire, as demonstrated on the learning curve. Additional work is required to demonstrate that the skill tested by the FluoroSim is the same skill that is required for intraoperative DHS guidewire insertion. However, use of the FluoroSim provides improvement in skills with extra-clinical training opportunities for orthopaedic trainees. Clinical Relevance: FluoroSim has demonstrated validity and training effect. It has the potential to be approved for possible use on patients in the operating room to help surgeons with the operation. Consequently, operating time, accuracy of TAD, and surgical outcomes may all be improved.

Background and purpose — Simulation is an adjunct to surgical education. However, nothing can accurately simulate fluoroscopic procedures in orthopedic trauma. Current options for training with fluoroscopy are either intraoperative, which risks radiation, or use of expensive and unrealistic virtual reality simulators. We introduce FluoroSim, an inexpensive digital fluoroscopy simulator without the need for radiation.Patients and methods — This was a multicenter study with 26 surgeons in which everyone completed 1 attempt at inserting a guide-wire into a femoral dry bone using surgical equipment and FluoroSim. 5 objective performance metrics were recorded in real-time to assess construct validity. The surgeons were categorized based on the number of dynamic hip screws (DHS) performed: novices (< 10), intermediates (10–39) and experts (≥ 40). A 7-point Likert scale questionnaire assessed the face and content validity of FluoroSim.Results — Construct validity was present for 2 clinically validated metrics in DHS surgery. Experts and intermediates statistically significantly outperformed novices for tip–apex distance and for cut-out rate. Novices took the least number of radiographs. Face and content validity were also observed.Interpretation — FluoroSim discriminated between novice and intermediate or expert surgeons based on tip–apex distance and cut-out rate while demonstrating face and content validity. FluoroSim provides a useful adjunct to orthopedic training. Our findings concur with results from studies using other simulation modalities. FluoroSim can be implemented for education easily and cheaply away from theater in a safe and controlled environment.

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