Virtual-reality simulation to assess performance in hip fracture surgery

Poul Pedersen, Henrik Palm, Charlotte Ringsted, Lars Konge, Poul Pedersen, Henrik Palm, Charlotte Ringsted, Lars Konge

Abstract

Background and purpose: Internal fixation of hip fractures is a common and important procedure that orthopedic surgeons must master early in their career. Virtual-reality training could improve initial skills, and a simulation-based test would make it possible to ensure basic competency of junior surgeons before they proceed to supervised practice on patients. The aim of this study was to develop a reliable and valid test with credible pass/fail standards.

Methods: 20 physicians (10 untrained novices and 10 experienced orthopedic surgeons) each performed 3 internal fixation procedures of an undisplaced femoral neck fracture: 2 hook-pins, 2 screws, and a sliding hip screw. All procedures were preformed on a trauma simulator. Performance scores for each procedure were obtained from the predefined metrics of the simulator. The inter-case reliability of the simulator metrics was explored by calculation of intra-class correlation coefficient. Validity was explored by comparison between novices' and experts' scores using independent-samples t-test. A pass/fail standard was set by the contrasting-groups method and the consequences were explored.

Results: The percentage of maximum combined score (PM score) showed an inter-case reliability of 0.83 (95% CI: 0.65-0.93) between the 3 procedures. The mean PM score was 30% (CI: 7-53) for the novices and 76% (CI: 68-83) for the experienced surgeons. The pass/fail standard was set at 58%, resulting in none of the novices passing the test and a single experienced surgeon failing the test.

Interpretation: The simulation-based test was reliable and valid in our setting, and the pass/fail standard could discriminate between novices and experienced surgeons. Potentially, training and testing of future junior surgeons on a virtual-reality simulator could ensure basic competency before proceeding to supervised practice on patients.

Figures

Figure 1.
Figure 1.
Distribution of percentage of maximum (PM) score for novices and experienced surgeons. Using the contrasting-groups method, the pass/fail standard for the test was determined from the intersection of the distributions (58%).
Figure 2.
Figure 2.
Box-plot showing percentage of maximum score (PM score) for novices and experienced surgeons, respectively. The line illustrates the consequence of the pass/fail standard. None of the novices passed the test. One of the experienced surgeons also failed the test.

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