Hip-fracture osteosynthesis training: exploring learning curves and setting proficiency standards

Abstract

Background and purpose — Orthopedic surgeons must be able to perform internal fixation of proximal femoral fractures early in their career, but inexperienced trainees prolong surgery and cause increased reoperation rates. Simulation-based virtual reality (VR) training has been proposed to overcome the initial steep part of the learning curve but it is unknown how much simulation training is necessary before trainees can progress to supervised surgery on patients. We determined characteristics of learning curves for novices and experts and a pass/fail mastery-learning standard for junior trainees was established. Methods — 38 first-year residents and 8 consultants specialized in orthopedic trauma surgery performed cannulated screws, Hansson pins, and sliding hip screw on the Swemac TraumaVision VR simulator. A previously validated test was used. The participants repeated the procedures until they reached their learning plateau. Results — The novices and the experts reached their learning plateau after an average of 169 minutes (95% CI 152–87) and 143 minutes (CI 109–177), respectively. Highest achieved scores were 92% (CI 91–93) for novices and 96% (CI 94–97) for experts. Plateau score, defined as the average of the 4 last scores, was 85% (CI 82–87) and 92% (CI 89–96) for the novices and the experts, respectively. Interpretation — Training time to reach plateau varied widely and it is paramount that simulation-based training continues to a predefined standard instead of ending after a fixed number of attempts or amount of time. A score of 92% comparable to the experts’ plateau score could be used as a mastery learning pass/fail standard.

HipSim — hip fracture surgery simulation utilizing the Learning Curve–Cumulative Summation test (LC-CUSUM)

“…In contrast to previous studies with the simulator, this study is the first to include clinical variability in the simulation program. Previous studies have considered the validity of the simulator and explored learning curves of repetitively operating on the same side of a single patient (Pedersen et al 2014 , Akhtar et al 2015 , Sugand et al 2015 , Gustafsson et al 2019 ). We strongly believe that the introduction of clinical complexity is essential to exploit the full learning potential of the VR simulation program.…”

“…The construct validity of the virtual reality (VR) simulator (TraumaVision, Swemac Simulation AB, Sweden) has been established, i.e., the simulator performance correlates with surgical experience (Pedersen et al 2014 , Akhtar et al 2015 , Gustafsson et al 2019 ). Notably, the simulator can discriminate between novices (< 10 DHS), intermediates, and experts (Akhtar et al 2015 ).…”

“…Virtual reality (VR) simulation training has been introduced to address the issue of training, and previous studies have demonstrated that VR training can ensure basic proficiency (Pedersen et al 2014 , Gustafsson et al 2019 ). Consequently, VR training in hip fracture surgery is available to 1st-year orthopedic residents in Denmark at an early stage of their orthopedic career and before applying for and enrolling in the 2nd–5th years of orthopedic residency.…”

Assessment of technical skill in hip fracture surgery using the postoperative radiograph

“…Ten cases was chosen because previous learning curve analysis of trainees performing simulated hip fracture osteosynthesis suggests that around ten repetitions are required for performance to stabilize in the associative learning phase. 23 For continuous outcomes, we compared the means between both groups using t -test, and tested whether the difference between groups was zero. For categorical outcomes, we conducted a chi-squared test of association, or Fisher’s exact test if cell counts were less than five.…”

Failure affects subjective estimates of cognitive load through a negative carry-over effect in virtual reality simulation of hip fracture surgery

“…Virtual reality (VR) simulation training has been introduced to address the issue of training, and previous studies have demonstrated that VR simulation training can ensure basic proficiency of the junior surgeon before continued supervised clinical training [2, 3]. Consequently, VR simulation in hip fracture surgery is available to Danish orthopedic residents at an early stage of their training.…”