Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
J Bone Joint Surg Am. 2019 Feb 6;101(3):e10. doi: 10.2106/JBJS.17.01089.
Education in microvascular surgery is limited by variable experience, a difficult learning curve, and potentially catastrophic complications caused by failed anastomoses. Furthermore, utilization of live-animal training models can be difficult because of lack of access and high maintenance costs. The purpose of this study was to determine the effectiveness and cost of a self-directed microvascular training curriculum utilizing synthetic microvessels and nonliving models in an orthopaedic residency program.
Twenty-five orthopaedic residents ranging from postgraduate year (PGY)-1 to PGY-4 were prospectively enrolled. The curriculum consisted of learning the basics of microsurgery on nonliving models and progressed to anastomoses on a 1-mm synthetic microvessel. Outcomes included Global Rating Scale (GRS) scores (5 to 25 points), patency, anastomosis time, comfort level (1 to 10 points), time to complete the curriculum, and curriculum utility (1 to 10 points). Blinded qualitative assessments (from 1 to 10 points) of pre-curriculum and post-curriculum anastomoses were made by 4 hand surgery faculty members. Outcome measures were obtained at baseline and post-curriculum. The curriculum cost was calculated as the setup cost and the maintenance cost per resident. Student t tests and Fisher exact tests were utilized for significance.
All residents successfully completed the curriculum. The mean anastomosis time (and standard deviation) decreased from 40 ± 3 minutes to 22 ± 4 minutes (p < 0.001). The mean GRS score improved from 12 ± 2 points to 18 ± 2 points (p < 0.01). Patency was achieved by 44% at baseline evaluation and by 96% at post-curriculum evaluation (p < 0.0001). The mean comfort level improved from 3 ± 1.2 points to 6 ± 1.7 points (p < 0.0001) on a scale of 1 to 10 points. Also on a scale of 1 to 10, the blinded mean qualitative anastomoses score improved from 4.8 ± 2.2 points (poor) to 8.0 ± 1.1 points (good) (p < 0.0001). The mean time to complete the curriculum was 5.5 ± 1.4 hours, and, on a scale of 1 to 10, curriculum utility was rated by the residents to be 8 ± 1.8 points. The cost of the initial setup was $1,795 with a yearly utilization cost per resident of $42.
The implementation of a self-directed curriculum utilizing synthetic microvessels and nonliving models demonstrated significant improvements in resident microvascular skill. This curriculum represents a modest startup cost and low yearly cost per resident.
微血管外科学的教育受到经验的差异、学习曲线的难度以及吻合口失败导致的潜在灾难性并发症的限制。此外，由于缺乏途径和高昂的维护成本，活体动物训练模型的利用可能会遇到困难。本研究的目的是确定在骨科住院医师培训计划中使用合成微管和非生物模型进行自我指导的微血管培训课程的有效性和成本。
前瞻性纳入了 25 名从住院医师 1 年（PGY-1）到住院医师 4 年（PGY-4）的骨科住院医师。课程包括在非生物模型上学习显微外科基础知识，并逐步进行 1 毫米合成微管吻合。结果包括总体评分（5 到 25 分）、通畅性、吻合时间、舒适度（1 到 10 分）、完成课程的时间以及课程实用性（1 到 10 分）。4 位手外科教员对课程前后的吻合术进行了盲法定性评估（1 到 10 分）。在课程前后获得了结果测量值。课程的成本计算为设置成本和每位住院医师的维护成本。采用学生 t 检验和 Fisher 精确检验进行显著性检验。
所有住院医师均成功完成了课程。吻合时间的平均值（标准差）从 40 ± 3 分钟减少到 22 ± 4 分钟（p < 0.001）。总体评分从 12 ± 2 分提高到 18 ± 2 分（p < 0.01）。基线评估时通畅率为 44%，课程后评估时为 96%（p < 0.0001）。舒适度平均值从 3 ± 1.2 分提高到 6 ± 1.7 分（p < 0.0001），评分为 1 到 10 分。在 1 到 10 分的评分中，盲法平均定性吻合术评分从 4.8 ± 2.2 分（差）提高到 8.0 ± 1.1 分（好）（p < 0.0001）。完成课程的平均时间为 5.5 ± 1.4 小时，住院医师对课程的实用性评分在 1 到 10 分之间为 8 ± 1.8 分。初始设置成本为 1795 美元，每位住院医师每年的使用成本为 42 美元。
使用合成微管和非生物模型的自我指导课程的实施显著提高了住院医师的微血管技能。该课程的启动成本适中，每位住院医师的年成本低。
