Most assessment of surgical trainees is based on measures of knowledge, with limited evaluation of their competence to actually perform various surgical procedures. In this study, the authors ...evaluated a tool they designed to assess a trainee's competence to perform an entire surgical procedure independently, regardless of procedure type or postgraduate year (PGY).
In phase 1, the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE) was piloted in the University of Ottawa's Division of Orthopaedic Surgery. In phase 2, the refined 11-item tool (8 items rated on a 5-point competency scale, 1 item assessing procedural competence, 2 feedback items) was used in the Divisions of Orthopaedic Surgery and General Surgery to assess residents' performance on 11 common procedures. Quantitative and qualitative analyses were conducted.
In phase 2, 34 orthopaedic and general surgeons assessed the performance of 37 residents in 163 procedures. ANOVA demonstrated an effect of PGY. Post hoc analysis found that total procedure scores for PGYs 1 and 2 were lower than those for PGY 3 (P<.001), and PGY 3 scores were lower than those for PGYs 4 and 5 (P<.02). Analysis of qualitative data indicated that the rating scale was practical and useful for surgeons and residents.
This novel evaluation tool successfully discriminated between junior and senior residents and identified surgical competency across various PGY levels regardless of procedure type. Multiple sources of evidence support the O-SCORE as a valid tool for the assessment of trainee operative competency.
Fully immersive virtual reality (VR) uses headsets to situate a surgeon in a virtual operating room to perform open surgical procedures. The aims of this study were to determine (1) if a VR ...curriculum for training residents to perform anterior approach total hip replacement (AA-THR) was feasible, (2) if VR enabled residents' performance to be measured objectively, and (3) if cognitive and motor skills that were learned with use of VR were transferred to the physical world.
The performance of 32 orthopaedic residents (surgical postgraduate years PGY-1 through 4) with no prior experience with AA-THR was measured during 5 consecutive VR training and assessment sessions. Outcome measures were related to procedural sequence, efficiency of movement, duration of surgery, and visuospatial precision in acetabular component positioning and femoral neck osteotomy, and were compared with the performance of 4 expert hip surgeons to establish competency-based criteria. Pretraining and post-training assessments on dry bone models were used to assess the transfer of visuospatial skills from VR to the physical world.
Residents progressively developed surgical skills in VR on a learning curve through repeated practice, plateauing, on average, after 4 sessions (4.1 ± 0.6 hours); they reached expert VR levels for 9 of 10 metrics (except femoral osteotomy angle). Procedural errors were reduced by 79%, assistive prompts were reduced by 70%, and procedural duration was reduced by 28%. Dominant and nondominant hand movements were reduced by 35% and 36%, respectively, and head movement was reduced by 44%. Femoral osteotomy was performed more accurately, and acetabular implant orientation improved in VR assessments. In the physical world assessments, experts were more accurate than residents prior to simulation, but were matched by residents after simulation for all of the metrics except femoral osteotomy angle. The residents who performed best in VR were the most accurate in the physical world, while 2 residents were unable to achieve competence despite sustained practice.
For novice surgeons learning AA-THR skills, fully immersive VR technology can objectively measure progress in the acquisition of surgical skills as measured by procedural sequence, efficiency of movement, and visuospatial accuracy. Skills learned in this environment are transferred to the physical environment.
The iconic Miller's pyramid, proposed in 1989, characterizes 4 levels of assessment in medical education ("knows," "knows how," "shows how," "does"). The frame work has created a worldwide awareness ...of the need to have different assessment approaches for different expected outcomes of education and training. At the time, Miller stressed the innovative use of simulation techniques, geared at the third level ("shows how"); however, the "does" level, assessment in the workplace, remained a largely uncharted area. In the 30 years since Miller's conference address and seminal paper, much attention has been devoted to procedures and instrument development for workplace-based assessment. With the rise of competency-based medical education (CBME), the need for approaches to determine the competence of learners in the clinical workplace has intensified. The proposal to use entrustable professional activities as a framework of assessment and the related entrustment decision making for clinical responsibilities at designated levels of supervision of learners (e.g., direct, indirect, and no supervision) has become a recent critical innovation of CBME at the "does" level. Analysis of the entrustment concept reveals that trust in a learner to work without assistance or supervision encompasses more than the observation of "doing" in practice (the "does" level). It implies the readiness of educators to accept the inherent risks involved in health care tasks and the judgment that the learner has enough experience to act appropriately when facing unexpected challenges. Earning this qualification requires qualities beyond observed proficiency, which led the authors to propose adding the level "trusted" to the apex of Miller's pyramid.
Optimum management for the elderly acetabular fracture remains undefined. Open reduction and internal fixation (ORIF) in this population does not allow early weight-bearing and has an increased risk ...of failure. This study aimed to define outcomes of total hip arthroplasty (THA) in the setting of an acetabular fracture and compared delayed THA after acetabular ORIF (ORIF delayed THA) and acute fixation and THA (ORIF acute THA).
All acetabular fractures in patients older than 60 years who underwent ORIF between 2007 and 2018 were reviewed (n = 85). Of those, 14 underwent ORIF only initially and required subsequent THA (ORIF delayed THA). Twelve underwent an acute THA at the time of the ORIF (ORIF acute THA). The ORIF acute THA group was older (81 ± 7 vs 76 ± 8; P < .01) but had no other demographic- or injury-related differences compared with the ORIF delayed THA group. Outcome measures included operative time, length of stay, complications, radiographic assessments (component orientation, leg-length discrepancy, heterotopic ossification), and functional outcomes using the Oxford Hip Score (OHS).
Operative time (P = .1) and length of stay (P = .5) for the initial surgical procedure (ORIF only or ORIF THA) were not different between groups. Four patients had a complication and required further surgeries; no difference was seen between groups. Radiographic assessments were similar between groups. The ORIF acute THA group had a significantly better OHS (40.1 ± 3.9) than the ORIF delayed THA group (33.6 ± 8.5) (P = .03).
In elderly acetabulum fractures, ORIF acute THA compared favorably (a better OHS, single operation/hospital visit, equivalent complications) with ORIF delayed THA. We would thus recommend that in patients with risk factors for failure requiring delayed THA (eg, dome or roof impaction) that ORIF acute THA be strongly considered.
During primary total hip arthroplasty, intra-operative calcar fractures have been historically treated with cerclage wires. However, interfragmentary screw fixation technique can possibly achieve the ...same results with technical advantages. The aim of this biomechanical study was to assess stability of calcar fractures fixed using interfragmentary screw technique compared to a traditional cerclage system specifically in context of total hip arthroplasty.
Thirty-two periprosthetic fractures were reduced using either a single cerclage cable or an intracortical positional screw perpendicular to the fracture line. Axial and torsional load testing was terminated after experimental model failure.
No significant difference was obtained for all output parameters when comparing cerclage wires versus interfragmentary screw fixation respectively. Load at failure: 8043 ± 712 N vs 7425 ± 854 N (p = 0.115). Load at calcar fracture propagation: 6240 ± 2207 N versus 6220 ± 966 N (p = 0.668). Maximum stiffness before failure: 617 ± 115 N/mm vs 839 ± 175 N/mm (p = 0.100) and stiffness at calcar fracture propagation reached 771 ± 153 Nmm vs 886 ± 129 N/mm (p = 0.197). Torque to failure levels obtained were 59.4 ± 7.1 N*m vs 60.9 ± 12.0 N*m (p = 0.908). Torque to calcar fracture propagation, 51.6 ± 6.1 N*m vs 48.5 ± 9.8 N*m (p = 0.298). Torsional stiffness at failure, 0.38 ± 0.03 N*m\deg. vs 0.43 ± 0.13 N*m\deg. (p = 0.465). Torsional stiffness at calcar fracture propagation were 0.37 ± 0.03 N*m\deg. vs 0.45 ± 0.17 N*m\deg. (p = 0.462).
The strength of fixation and stability of the implant were similar for both techniques. In the synthetic bone model tested, using an interfragmentary screw conveyed similar stability to the constructs in the management of an intra-operative medial calcar fractures. Thus, potentially giving surgeons an alternative option for intraoperative fracture fixation during primary total hip arthroplasty.
•Intraoperative calcar fractures compromise implant stability.•Classic calcar fracture fixation method not optimal for direct anterior approach.•No difference in stability gained from screw versus cable in synthetic bone models.
Purpose
Anemia has been shown to be a modifiable pre-operative, patient factor associated with outcome following arthroplasty. The aims of this retrospective study were to (1) ascertain the ...prevalence of preoperative anemia in patients undergoing primary and revision hip and knee arthroplasty at a tertiary referral center and (2) to test the association with outcome and whether it differs between primary and revision cases.
Methods
All hip and knee primary and revision arthroplasties performed at a Canadian academic, tertiary-care, arthroplasty center between 2012 and 2017 were included in this study. The study group consisted of 5944 patients, of which 5251 were primary Total Hip and Knee Arthroplasties or Hip Resurfacings and 693 were revision arthroplasties (65% hip revisions/35% knee revisions). Anemia was classified as per WHO definition (hemoglobin < 130 g/L for men and < 120 g/L for women). All anemic patients were grouped into mild, moderate or severe anemia. Length-of-stay, perioperative transfusion-rate, 90-day readmission, overall complication rate and reoperation rates were recorded. The effect of preoperative anemia and the effect of severity of the anemia was evaluated through multivariable regression analysis controlling for relevant covariates.
Results
Preoperatively, 15% (786/5251) of the primary patients and 47% (322/693) of the revision arthroplasty patients were anemic preoperatively. Anemic revision patients were 3.1 times more likely (95% CI: 1.47–6.33) to obtain blood transfusions during the hospital stay, compared to a 4.9 times higher risk in primary patients. The odds ratio to sustain any postoperative complication if anemic was 1.5 times higher (95% CI: 0.73–3.16) in revision patients and 1.7 in primary cases. In addition, the 90-day readmission rate among both groups was 1.6 times higher in anemic patients. Furthermore, anemic revision patients had a 5.3 days longer length of stay (95% CI: 2.63–7.91), compared to only 1 additional day in anemic primary patients (95% CI: 0.69–1.34).
Conclusion
In this study cohort, the prevalence of anemia in patients awaiting revision arthroplasty was 3 times higher (46.6%) than in primary arthroplasty patients (18.7%). Preoperative anemia was associated with similarly, inferior outcomes in both groups. To reduce postoperative complications and the “burden” associated with anemia, these findings strongly recommend optimizing the preoperative hemoglobin in all arthroplasty patients. However, revision patients are affected more frequently, and particular attention must therefore be taken to this growing group in the future.
Level of Evidence
Level III.
For total hip arthroplasty (THA), cognitive training prior to performing real surgery may be an effective adjunct alongside simulation to shorten the learning curve. This study sought to create a ...cognitive training tool (CTT) to perform anterior approach (AA)-THA, which was validated by expert surgeons, and test its use as a training tool compared with conventional material.
We employed a modified Delphi method with 4 expert surgeons from 3 international centers of excellence. Surgeons were independently observed performing THA before undergoing semistructured cognitive task analysis (CTA) and before completing successive rounds of surveys until a consensus was reached. Thirty-six surgical residents (postgraduate year PGY-1 through PGY-4) were randomized to cognitive training or training with a standard operation manual with surgical videos before performing a simulated AA-THA.
The consensus CTA defined THA in 11 phases, in which were embedded 46 basic steps, 36 decision points, and 42 critical errors and linked strategies. This CTA was mapped onto an open-access web-based CTT. Surgeons who prepared with the CTT performed a simulated THA 35% more quickly (time, mean 28 versus 38 minutes) with 69% fewer errors in instrument selection (mean 29 versus 49 instances), and required 92% fewer prompts (mean 13 versus 25 instances). They were more accurate in acetabular cup orientation (inclination error, mean 8° versus 10°; anteversion error, mean 14° versus 22°).
This validated CTT for arthroplasty provides structure for competency-based learning. It is more effective at preparing orthopaedic trainees for a complex procedure than conventional materials, as well as for learning sequence, instrumentation utilization, and motor skills.
Cognitive training combines education on decision-making, knowledge, and technical skill. It is an inexpensive technique to teach surgeons to perform hip arthroplasty and is more effective than current preparation methods.
(1) Assess outcomes of acetabular open reduction and internal fixation (ORIF) in the elderly, (2) investigate factors influencing outcome, and (3) compare outcomes after low-energy and high-energy ...mechanisms of injury.
Retrospective case series.
Level 1 trauma center.
Seventy-eight patients older than 60 years (age: 70.1 ± 7.4; 73.1% males).
ORIF for acetabular fractures.
Complications, reoperation rates, Oxford Hip Score (OHS), and joint preservation and development of symptomatic osteoarthritis. Cases with osteoarthritis, OHS < 34, and those who required subsequent total hip arthroplasty were considered as poor outcome.
At a mean follow-up of 4.3 ± 3.7 years, 11 cases post-ORIF required a total hip arthroplasty. The 7-year joint survival post-ORIF was 80.7 ± 5.7%. Considering poor outcome as failure, the 7-year joint survival was 67.0 ± 8.9%. The grade of reduction was the most significant factor associated with outcome post-ORIF. Female sex (P = 0.03), pre-existing osteoporosis (P = 0.03), low-energy trauma (P = 0.04), and Matta grade (P = 0.002) were associated with poor outcome. Patients with associated both-column fractures were more likely to have nonanatomic reduction (P = 0.008). After low-energy trauma, joint survivorship was 36.6 ± 13.5% at 7 years compared with 75.4 ± 7.4% in the high-energy group when considering poor outcome as an end point (log rank P = 0.006). The cohort's mean OHS was 37.9 ± 9.3 (17-48).
We recommend ORIF whenever an anatomic reduction is feasible. However, achievement and maintenance of anatomic reduction are a challenge in the elderly, specifically in those with low-energy fractures involving both columns, prompting consideration for alternative management strategies.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
The anterior approach (AA) to total hip arthroplasty (THA) has advantages for patients and healthcare providers. However, some studies have reported high rates of adverse events when introducing ...AA-THA. This was not consistent with our center’s experience, where 4 senior surgeons safely introduced AA-THA into practice. The purpose of this study is to define the adverse event rates associated with the introduction of AA-THA by a group of experienced surgeons at a single tertiary care center and define experiential factors that may modify adverse event rates.
Retrospective review of prospectively collected data for an observational cohort of all patients undergoing a THA between 2006 and 2017 was conducted. Four senior surgeons at a single institution operated on 1087 primary elective hips using AA-THA.
Between 2006 and 2016, AA-THA rose from 1.5% to 53.2% of annual THA. Adverse events included intraoperative events, early postoperative periprosthetic fractures, dislocation, implant failure, early infection, and wound complications. We observed an overall 90-day adverse event rate of 6.4% (of 1087 hips). The adverse event rate was 41.6% (of 12 hips) in the first 12 months of the study period and 3.6% (of 166 hips) in the final 12 months of the study period reviewed. Sixty hips (5.5%) required a reoperation with or without revision of components, 1 (8.3%) in the first 12 months of the study period and 1 (0.6%) in the final 12 months of the study period. Infection and wound complications were the most common causes of reoperation at 1.8% for all cases (20 hips). Higher rates of adverse events are associated with early procedures (n ≤ 15) for all surgeons but showed no statistically significant impact on 5-year survival rate.
Our experience demonstrates that AA-THA can be introduced into practice with an acceptable adverse event rate when compared with other approaches to THA. As expected the incidence of adverse events is higher in the early part of the learning curve. Surgeon mentoring in the first 20 cases should be considered to minimize risk of adverse events.
Therapeutic Level III.
Abstract Background Added modular junction has been associated with implant-related failures. We report our experience with a titanium-titanium modular neck-stem interface to assess complications, ...possible clinical factors influencing use of neck modularity, and whether modularity reduced the incidence of dislocation. Methods A total of 809 total hip arthroplasties completed between 2005 and 2012 from a prospectively collected database were reviewed. The mean follow-up interval was 5.7 years (3.3-10.3 years). Forty-five percent were male (360 of 809), and 55% were female (449 of 809). All stems were uncemented PROFEMUR TL (titanium, flat-tapered, wedge) or PROFEMUR Z (titanium, rectangular, dual-tapered) with a titanium neck. Results Increased modularity (anteverted/retroverted and anteverted/retroverted varus/valgus (anteverted/retroverted + anteverted/retroverted varus/valgus) was used in 39.4% (135 of 343) of cases using the posterior approach compared with 6.8% (20 of 293) of anterior and 23.7% (41 of 173) of lateral approaches. Four males sustained neck fractures at a mean of 95.5 months (69.3-115.6 months) after primary surgery. Overall dislocation rate was 1.1% (9 of 809). The posterior approach had both the highest utilization of increased modularity and the highest dislocation rate (2.3%), of which the most were recurrent. The anterior (0.3%) and lateral (0%) approaches had lower dislocation rates with no recurrences. Conclusion At a mean 5.7 years, our experience demonstrates a low neck fracture (0.5%) and a low dislocation rate (1.1%). Use of increased modularity may not improve dislocation risk for the posterior approach. Continued surveillance of this group will be necessary to determine long term survivorship of this modular titanium implant.
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