Is Two-on-one Instruction in Virtual Reality Simulation-based Training of Operating Fractures of the Hip for Medical Students as Effective as One-on-one Instruction

Dyad Versus Single Instruction for Simulation-based Training in Proximal Femoral Fracture Osteosynthesis: a Non-inferiority Randomized Controlled Trial

The training of orthopedic surgeons has historically relied heavily on an apprenticeship model as the primary way of teaching the various procedures an aspiring surgeon needs to master. However, due to work-hour restrictions, demand for operating room efficiency, lack of supervisors and a growing focus and concern for patient safety, this model is challenged. As the importance of proper education and supervision of surgeons in training is still monumental, simulation-based training (SBT) has gained popularity within most medical specialties, as it provides a safe, and realistic room for training, where surgeons can effectively enhance their operating technique without posing a threat to patient safety. Techniques within orthopedic surgery are no exception to this tendency, and several virtual reality simulators and SBT courses has been developed. This includes the well-established SBT course in proximal femoral fracture (PFF) osteosynthesis, where evidence supported mastery standards for antegrade nailing, dynamic hip screw, Hansson pins and canulated screws have been established. A course that is recommended in the national curriculum for Danish orthopedic surgeons in training.

This change into a more technology- and simulation-based training does however pose challenges, that needs to be acknowledged and addressed to ensure the quality of the education and clinical skills of the orthopedic surgeons.

A key challenge is the limited resource of qualified instructors. These instructors are mainly experienced surgeons with a demanding and busy schedule, who teach part time in addition to their clinical work. It has previously been shown that teaching skills are to be taught by doctors and that good clinicians are not automatically good educators. With the burden of a busy clinical schedule, these experienced surgeons have difficulties finding the time to learn teaching skills.

It can therefore be challenging to educate enough qualified instructors. This poses a rising concern as the field of SBT is only expected to grow, with more courses in continuous development. Thus, potentially limiting the accessibility to orthopedic SBT courses, including the PFF course.

A possible solution for this challenge is dyad introductions. By converting one-on-one introduction to SBT for trainees into one-on-two introduction, it is possible to double the number of participants getting introductions without increasing the teaching load or expenses. This could significantly reduce the needed faculty time per trainee. Several studies have shown beneficial learning outcomes of dyad training. However, it seems, that the positive effects of dyad training cannot be translated into all types of medical simulations, and some studies suggests that the complexity and nature of the simulation defines whether dyad training is beneficial . It is theorized, that the effect of dyad training is caused by the learning of motor skills through mirror neurons during observation, and the distribution of knowledge during complex simulations according to the cognitive load theory. This suggests, that dyad training may be most beneficial in complex simulations requiring high levels of motor skills such as complex surgical procedures.

To our knowledge, no studies exist that examines whether dyad introduction can be equally used in the simulations of orthopedic procedures in general or PFF surgery specifically.

The aim of this study was to examine whether dyad introduction is non-inferior to the current one-on- one student introduction.

Study Overview

• Status: Recruiting
• Conditions: Learning Curves and Outcomes of Simulation-based Training
• Intervention / Treatment: Behavioral: Dyad instruction

• Study Type: Interventional
• Enrollment (Estimated): 62
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Amandus Gustafsson, MD, PhD; Phone Number: 4526792011; Email: amandus.gustafsson.02@regionh.dk
• Study Contact Backup: Name: Mads E Jacobsen, MD; Phone Number: 4560777357; Email: mads.emil.jacobsen@regionh.dk

Study Locations

• Denmark
  • Copenhagen, Denmark, 2100
    • Recruiting
    • Copenhagen Academy for Medical Education and Simulation
    • Contact: Amanuds Gustafsson, MD, PhD; Phone Number: 4526792011; Email: amandus.gustafsson.02@regionh.dk
    • Contact: Mads E Jacobsen, MD; Email: mads.emil.jacobsen@regionh.dk
    • Principal Investigator: Mikkel ES Nielsen, Medical Student

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult; Older Adult
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

• PGY 1 and 2 doctors working in an orthopeadic department

Exclusion Criteria:

• More than 10 osteosynthesis of proximal femoral fractures performed as the primary surgeon.
• Failure to achieve mastery within the 4-month follow-up window.s

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Basic Science
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
No Intervention: One-on-one instruction to simulation-based training; The usual instruction with one instructor instructing the trainee in simulation-based training in osteosynthesis of proximal femoral fractures
Active Comparator: Dyad instruction; Dyad or two-on-one instruction, where two trainees are instructed by an instructor at the same time and with the same time usage as in the non-intervention arm.	Behavioral: Dyad instruction; Rather than being instructed solo or one-on-one the trainees are instructed in pairs of two (dyad).

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of two-hour self-trainin sessions to achieve mastery standard	The embeeded test in the simulator has established mastery standards. The primary outcome is how many two hour training sessions the trainees has to attend to achieve the mastery standard	From enrollment until mastery is achieved, or up to 4 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Hands-on training time	The hands-on time the trainee is actively training on the simulator	From enrollment until mastery is achieved, or up to 4 months
Test score of each iteration of training	Test scores for each iteration of training until the trainee achieves the mastery standard	From enrollment until mastery is achieved, or up to 4 months
Failure to achieve mastery standard	Number of participants who do not achieve the mastery standard within 9 training sessions or within 4 months of enrollment (whichever comes first).	Up to 4 months from enrollment
Calendar time to mastery	Time from enrollment to achievement of the mastery standard within the 4-month follow-up period. Participants not achieving mastery within the window will be classified accordingly.	Up to 4 months from enrollment.

Collaborators and Investigators

• Sponsor: Copenhagen Academy for Medical Education and Simulation

Study record dates

Study Major Dates

• Study Start (Actual): October 9, 2024
• Primary Completion (Estimated): October 15, 2026
• Study Completion (Estimated): February 15, 2027

Study Registration Dates

• First Submitted: September 16, 2024
• First Submitted That Met QC Criteria: September 23, 2024
• First Posted (Actual): September 25, 2024

Study Record Updates

• Last Update Posted (Actual): February 11, 2026
• Last Update Submitted That Met QC Criteria: February 7, 2026
• Last Verified: February 1, 2026

More Information

Terms related to this study

• Keywords: Medical Education; Simulation-based training; Osteosynthesis; Proximal femoral fracture; Mastery standards; Orthopeadic surgery; Dyad instruction
• Additional Relevant MeSH Terms: Wounds and Injuries; Leg Injuries; Fractures, Bone; Femoral Fractures; Hip Injuries; Hip Fractures; Femoral Neck Fractures; Proximal Femoral Fractures
• Other Study ID Numbers: F-24056399

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED
• IPD Plan Description: We will only share IPD based on a specific request or by demand of a journal

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No