Immersive virtual reality enables technical skill acquisition for scrub nurses in complex revision total knee arthroplasty.

INTRODUCTION: Immersive Virtual Reality (iVR) is a novel technology which can enhance surgical training in a virtual environment without supervision. However, it is untested for the training to select, assemble and deliver instrumentation in orthopaedic surgery-typically performed by scrub nurses. This study investigates the impact of an iVR curriculum on this facet of the technically demanding revision total knee arthroplasty. MATERIALS AND METHODS: Ten scrub nurses completed training in four iVR sessions over a 4-week period. Initially, nurses completed a baseline real-world assessment, performing their role with real equipment in a simulated operation assessment. Each subsequent iVR session involved a guided mode, where the software taught participants the procedural choreography and assembly of instrumentation in a simulated operating room. In the latter three sessions, nurses also undertook an assessment in iVR. Outcome measures were related to procedural sequence, duration of surgery and efficiency of movement. Transfer of skills from iVR to the real world was assessed in a post-training simulated operation assessment. A pre- and post-training questionnaire assessed the participants knowledge, confidence and anxiety. RESULTS: Operative time reduced by an average of 47% across the 3 unguided sessions (mean 55.5 ± 17.6 min to 29.3 ± 12.1 min, p > 0.001). Assistive prompts reduced by 75% (34.1 ± 16.8 to 8.6 ± 8.8, p < 0.001), dominant hand motion by 28% (881.3 ± 178.5 m to 643.3 ± 119.8 m, p < 0.001) and head motion by 36% (459.9 ± 99.7 m to 292.6 ± 85.3 m, p < 0.001). Real-world skill improved from 11% prior to iVR training to 84% correct post-training. Participants reported increased confidence and reduced anxiety in scrubbing for rTKA procedures (p < 0.001). CONCLUSIONS: For scrub nurses, unfamiliarity with complex surgical procedures or equipment is common. Immersive VR training improved their understanding, technical skills and efficiency. These iVR-learnt skills transferred into the real world

Factors Associated with Revision Surgery after Internal Fixation of Hip Fractures

Background: Femoral neck fractures are associated with high rates of revision surgery after management with internal fixation. Using data from the Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trial evaluating methods of internal fixation in patients with femoral neck fractures, we investigated associations between baseline and surgical factors and the need for revision surgery to promote healing, relieve pain, treat infection or improve function over 24 months postsurgery. Additionally, we investigated factors associated with (1) hardware removal and (2) implant exchange from cancellous screws (CS) or sliding hip screw (SHS) to total hip arthroplasty, hemiarthroplasty, or another internal fixation device. Methods: We identified 15 potential factors a priori that may be associated with revision surgery, 7 with hardware removal, and 14 with implant exchange. We used multivariable Cox proportional hazards analyses in our investigation. Results: Factors associated with increased risk of revision surgery included: female sex, [hazard ratio (HR) 1.79, 95% confidence interval (CI) 1.25-2.50; P = 0.001], higher body mass index (fo

Augmented reality for arthroplasty training - a randomised controlled trial of simulator-based training for acetabular cup orientation skills

Background: Accurate implant orientation reduces wear and increases stability in arthroplast y. This is a technically demanding skill. Augmented Reality headsets overlay digital information over the real world. We have developed an enhanced AR headset capable of tracking bony anatomy in relation to an implant. Questions/Purposes: The purpose of t his study was to validate this enhanced AR headset in the training simulator setting as determined by (1) quantitative assessments accurately orientating an acetabular component, and (2) a questionnaire regarding the realism of the task, acceptability of the technology, and its potential role for surgical training. Methods: Twenty - four novice surgeons voluntarily participated in a simulation trial. Demographics and baseline performance in orientating an acetabular implant to six patient - specific values o n the phantom pelvis, were collected prior to training. All participants received standardised educational lectures based around four clinical vignettes on hip surgery to normalise their knowledge. Participants were randomised to two groups, completing fo ur, once - weekly sessions of baseline assessment, training, and re - assessment. One group trained using AR (with live holographic feedback of orientation), and the other received one - on - one tuition from an expert surgeon (ES). The solid - angle error in degree s between the planned and achieved orientations was measured. Participants completed baseline assessments, then training, and then assessment in this fashion after each weekly session, and a validated post - training questionnaire evaluating their experience s. Results: Novice surgeons of similar experience in both groups performed with a similar error prior to training ( Baseline ES mean error 16° ± SD 7° compared to AR 14±7°, p>0.05 ). During training, participants achieved average errors in orientations of 1±1° using AR, and 6±4° when guided by the ES (p0.05). In post - training evaluation, 92% of participants would use the AR platform as a training tool for developing visuospati al skill, and 86% for procedure - specific rehearsal. 82% preferred ES for learning about orientation, but 58% preferred AR for practicing it. Conclusions: A novel head - mounted AR platform tracked an implant in relation to bony anatomy to a clinically - relev ant level of accuracy. It delivered training to novice surgeons for acquiring and retaining skills to orientate it, as effectively as an expert surgeon. In both groups, accuracy remained below ‘expert’ level proficiency (<5° error). Participants considered the AR platform feasible and useful as a training tool, with potential as an adjunct to learning in the operating theatre

Validating a global rating scale to monitor individual resident learning curves during arthroscopic knee meniscal repair.

PURPOSE: To determine whether a global rating scale (GRS) with construct validity can also be used to assess the learning curve of individual orthopaedic trainees during simulated arthroscopic knee meniscal repair. METHODS: An established arthroscopic GRS was used to evaluate the technical skill of 19 orthopaedic residents performing a standardized arthroscopic meniscal repair in a bioskills laboratory. The residents had diagnostic knee arthroscopy experience but no experience with arthroscopic meniscal repair. Residents were videotaped performing an arthroscopic meniscal repair on 12 separate occasions. Their performance was assessed by use of the GRS and motion analysis objectively measuring the time taken to complete tasks, path length of the subject's hands, and number of hand movements. One author assessed all 228 videos, whereas 2 other authors rated 34 randomly selected videos, testing the interobserver reliability of the GRS. The validity of the GRS was tested against the motion analysis. RESULTS: Objective assessment with motion analysis defined the surgeon's learning curve, showing significant improvement by each subject over 12 episodes (P &lt; .0001). The GRS also showed a similar learning curve with significant improvements in performance (P &lt; .0001). The median GRS score improved from 15 of 34 (interquartile range, 14 to 17) at baseline to 22 of 34 (interquartile range, 19 to 23) in the final period. There was a moderate correlation (P &lt; .0001, Spearman test) between the GRS and motion analysis parameters (r = -0.58 for time, r = -0.58 for path length, and r = -0.51 for hand movements). The inter-rater reliability among 3 trained assessors using the GRS was excellent (Cronbach α = 0.88). CONCLUSIONS: When compared with motion analysis, an established arthroscopic GRS, with construct validity, also offers a moderately feasible method to monitor the learning curve of individual residents during simulated knee meniscal repair. CLINICAL RELEVANCE: An arthroscopic GRS can be used for monitoring skill improvement during knee meniscal repair and has the potential for use as a training and assessment tool in the real operating room

Evidence in managing traumatic anterior shoulder instability: a scoping review.

BACKGROUND: Traumatic anterior shoulder instability (TASI) accounts for 95% of glenohumeral dislocations and is associated with soft tissue and bony pathoanatomies. Non-operative treatments include slings, bracing and physiotherapy. Operative treatment is common, including bony and soft-tissue reconstructions performed through open or arthroscopic approaches. There is management variation in patient pathways for TASI including when to refer and when to operate. METHODS: A scoping review of systematic reviews, randomised controlled trials, comparing operative with non-operative treatments and different operative treatments were the methods followed. Search was conducted for online bibliographic databases and reference lists of relevant articles from 2002 to 2012. Systematic reviews were appraised using AMSTAR (assessment of multiple systematic reviews) criteria. Controlled trials were appraised using the CONSORT (consolidation of standards of reporting trials) tool. RESULTS: Analysis of the reviews did not offer strong evidence for a best treatment option for TASI. No studies directly compare open, arthroscopic and structured rehabilitation programmes. Evaluation of arthroscopic studies and comparison to open procedures was difficult, as many of the arthroscopic techniques included are no longer used. Recurrence rate was generally considered the best measure of operative success, but was poorly documented throughout all studies. There was conflicting evidence on the optimal timing of intervention and no consensus on any scoring system or outcome measure. CONCLUSIONS: There is no agreement about which validated outcome tool should be used for assessing shoulder instability in patients. There is limited evidence regarding the comparative effectiveness of surgical and non-surgical treatment of TASI, including a lack of evidence regarding the optimal timing of such treatments. There is a need for a well-structured randomised control trial to assess the efficacy of surgical and non-surgical interventions for this common type of shoulder instability

Do patient-specific instruments (PSI) for UKA allow non-expert surgeons to achieve the same saw cut accuracy as expert surgeons?

INTRODUCTION: High-volume unicompartmental knee arthroplasty (UKA) surgeons have lower revision rates, in part due to improved intra-operative component alignment. This study set out to determine whether PSI might allow non-expert surgeons to achieve the same level of accuracy as expert surgeons. MATERIALS AND METHODS: Thirty-four surgical trainees with no prior experience of UKA, and four high-volume UKA surgeons were asked to perform the tibial saw cuts for a medial UKA in a sawbone model using both conventional and patient-specific instrumentation (PSI) with the aim of achieving a specified pre-operative plan. Half the participants in each group started with conventional instrumentation, and half with PSI. CT scans of the 76 cut sawbones were then segmented and reliably orientated in space, before saw cut position in the sagittal, coronal and axial planes was measured, and compared to the pre-operative plan. RESULTS: The compound error (absolute error in the coronal, sagittal and axial planes combined) for experts using conventional instruments was significantly less than that of the trainees (11.6°±4.0° v 7.7° ±2.3º, p = 0.029). PSI improved trainee accuracy to the same level as experts using conventional instruments (compound error 5.5° ±3.4º v 7.7° ±2.3º, p = 0.396) and patient-specific instruments (compound error 5.5° ±3.4º v 7.3° ±4.1º, p = 0.3). PSI did not improve the accuracy of high-volume surgeons (p = 0.3). CONCLUSIONS: In a sawbone model, PSI allowed inexperienced surgeons to achieve more accurate saw cuts, equivalent to expert surgeons, and thus has the potential to reduce revision rates. The next test will be to determine whether these results can be replicated in a clinical trial