MSk Lab, Imperial College London, London, United Kingdom.
Royal National Orthopedic Hospital, Stanmore, United Kingdom.
J Bone Joint Surg Am. 2019 Sep 4;101(17):e88. doi: 10.2106/JBJS.18.00928.
FluoroSim, a novel fluoroscopic simulator, can be used to practice dynamic hip screw (DHS) guidewire insertion in a high-fidelity clinical scenario. Our aim was to demonstrate a training effect in undergraduate medical students who are not familiar with this operation and its simulation.
Forty-five undergraduate medical students were recruited and randomized to either training (n = 23) or control (n = 22) cohorts. The training cohort had more exposure to FluoroSim (5 attempts each week) over a 2-week period (with a 1-week washout period in between) compared with the control cohort (a single attempt 1 week apart) over a 2-week period. Five real-time objective performance metrics were recorded: (1) tip-apex distance (TAD) (mm), (2) predicted cut-out rate (%), (3) total procedural time (sec), (4) total number of radiographs (n), and (5) total number of guidewire retries (n).
At baseline, there was no significant difference in the performance metrics, which confirmed the absence of a selection bias. The intragroup training effect demonstrated a significant improvement in all metrics for the training cohort only. A significant difference between groups was demonstrated as the training cohort significantly outperformed the control cohort in 3 metrics (procedural time [25%], number of radiographs [57%], and number of guidewire retries [100%]; p < 0.001). A learning curve showed an inversely proportional correlation between frequency of attempts and procedural time as well as the number of digital fluoroscopic radiographs that were made, indicating the development of psychomotor skills. There was also an improved baseline of the learning curve after the 1-week washout period, suggesting skill retention.
Skill acquisition with the FluoroSim system was demonstrated with repeat exposure in a safe, radiation-free high-fidelity clinical simulation with actual operating room equipment. The task of DHS guidewire insertion requires cognitive and psychomotor skills that take a variable number of attempts to acquire, as demonstrated on the learning curve. Additional work is required to demonstrate that the skill tested by the FluoroSim is the same skill that is required for intraoperative DHS guidewire insertion. However, use of the FluoroSim provides improvement in skills with extra-clinical training opportunities for orthopaedic trainees.
FluoroSim has demonstrated validity and training effect. It has the potential to be approved for possible use on patients in the operating room to help surgeons with the operation. Consequently, operating time, accuracy of TAD, and surgical outcomes may all be improved.
FluoroSim 是一种新型的透视模拟器，可用于在高保真临床环境下练习动态髋螺钉（DHS）导丝插入。我们的目的是证明对不熟悉该操作及其模拟的医学生进行培训的效果。
招募了 45 名医学生，并将其随机分为培训（n=23）和对照组（n=22）。与对照组（每周一次，间隔 1 周）相比，培训组在 2 周内有更多机会接触 FluoroSim（每周 5 次尝试），并且在 1 周的洗脱期之间。记录了 5 个实时客观绩效指标：（1）尖端-顶点距离（TAD）（mm），（2）预测切出率（%），（3）总手术时间（sec），（4）总放射片数（n）和（5）导丝重试总数（n）。
在基线时，两组的表现指标没有差异，这证实了不存在选择偏倚。仅培训组的组内培训效果显示所有指标均有显著提高。两组之间的差异表明，培训组在 3 项指标上的表现明显优于对照组（手术时间[25%]，放射片数量[57%]和导丝重试次数[100%]；p <0.001）。学习曲线表明，尝试次数与手术时间以及进行的数字透视放射片数量之间呈反比关系，表明运动技能的发展。在 1 周洗脱期后，学习曲线的基线也得到了改善，表明技能保留。
在安全、无辐射的高保真临床模拟环境中，使用实际手术室设备重复接触 FluoroSim 系统，可证明技能的获得。 DHS 导丝插入任务需要认知和运动技能，需要进行多次尝试才能掌握，如学习曲线所示。需要做更多的工作来证明 FluoroSim 测试的技能与 DHS 导丝术中插入所需的技能相同。但是，使用 FluoroSim 可以为骨科受训者提供额外的临床培训机会，从而提高技能。
FluoroSim 已证明具有有效性和培训效果。它有可能被批准在手术室中用于患者，以帮助外科医生进行手术。因此，手术时间，TAD 的准确性和手术结果都可能得到改善。
