A Dedicated Simulator Training Curriculum Improves Resident Performance in Surgical Management of Pediatric Supracondylar Humerus Fractures

Abstract

Background: The primary goal of including simulation in residency training is to improve technical skills while working outside of the operating room. Such simulation-related skill improvements have seldom been measured in the operating room. This is largely because uncontrolled variables, such as injury severity, patient comorbidity, and anatomical variation, can bias evaluation of an operating surgeon's skill. In this study, performance during the wire navigation phase of pediatric supracondylar humerus fracture fixation was quantitatively compared between 2 groups of orthopaedic residents: a standard training group consisting of residents who participated in a single simulator session of wire navigation training and an expanded training group consisting of residents who participated in a dedicated multifaceted wire navigation simulation training curriculum.

Methods: To evaluate performance in the operating room, the full sequence of fluoroscopic images collected during wire navigation was quantitatively analyzed. Objective performance metrics included number of fluoroscopic images acquired, duration from placement of the first wire to that of the final wire, and wire spread at the level of the fracture. These metrics were measured from 97 pediatric supracondylar humerus fracture pinning surgeries performed by 28 different orthopaedic residents.

Results: No differences were observed between the groups for wire spread in the final fluoroscopic images (t(94) = 0.75, p = 0.45), an important clinical objective of the surgery. Residents who received the expanded simulator training used significantly fewer fluoroscopic images (mean of 46 vs. 61 images, t(85) = 2.25, p < 0.03) and required less time from first to final wire placement (mean of 11.2 vs. 14.9 minutes, t(83) = 2.53, p = 0.013) than the standard training group. A post hoc review of Accreditation Council for Graduate Medical Education case logs for 24 cases from the standard training group and for 21 cases from the expanded training group indicated that, at the time of surgeries, residents who received expanded training had completed fewer comparable cases than residents in the standard training group (mean of 13 vs. 21, t(42) = 2.40 p = 0.02). Further regression analysis indicated that the expanded simulator training produced an effect comparable with that associated with completing 10.5 similar surgical case experiences.

Conclusions: This study demonstrates that training on a wire navigation simulator can lead to improved performance in the operating room on a critical skill for all orthopaedic residents. By taking fewer images and less time while maintaining sufficient pin spread, simulator-trained residents were objectively measured to have improved performance in comparison with residents who had not participated in the pediatric elbow simulator curriculum.

Clinical relevance: As programs aim to provide safe and effective training for critical orthopaedic skills such as pinning a pediatric elbow, this study demonstrates a simulator curriculum that has demonstrated the transfer of skill from a learning environment to the operating room.

Fig. 1

Fig. 1-A The pediatric supracondylar humerus fracture surgical simulator. Fig. 1-B A resident searches for a start position on the capitellum. Fig. 1-C The resident drives the wire into the simulated elbow. Fig. 1-D Simulated fluoroscopy images are displayed that show progress in pin placement.

Fig. 2

An anteroposterior fluoroscopic image illustrating the navigation of the second wire to fixate a pediatric supracondylar humerus fracture.

Fig. 3

Pediatric supracondylar humerus fracture (SCH Fx) cases included or excluded based on specific inclusion/exclusion criteria.

Fig. 4

After clicking on the medial and lateral aspects of the humerus, feedback informs the resident whether they have correctly identified the fracture line. Properly identifying the fracture line is critical to ensuring sequential pins have appropriate spread at the fracture.

Fig. 5

The left 2 images illustrate the circle (bubble) target exercise. These targets provide guided positions for trainees to place their pins when learning how to build their pin construct. In the images on the right, a projected line shows the path the wire will take if advanced further.

Fig. 6

Duration, number of images, and wire spread for each simulator training cohort.

Fig. 7

Scatterplot of the natural log of the number of images in the wire navigation portion of the surgery vs. the number of similar cases logged by the resident performing the wire navigation. The blue circles represent cases in which the resident had participated in the standard simulator training. The red squares represent cases in which the resident had the expanded simulator training. The blue line represents the regression for the standard training cases and the red line the regression of the expanded training cases.