James Hannah K, Pattison Giles T R, Griffin James, Fisher Joanne D, Griffin Damian R
Department of Trauma & Orthopaedic Surgery, University Hospitals Coventry and Warwickshire, Coventry, UK.
Warwick Clinical Trials Unit, Warwick Medical School, Coventry, UK.
Bone Jt Open. 2023 Aug 21;4(8):602-611. doi: 10.1302/2633-1462.48.BJO-2022-0143.R1.
To evaluate if, for orthopaedic trainees, additional cadaveric simulation training or standard training alone yields superior radiological and clinical outcomes in patients undergoing dynamic hip screw (DHS) fixation or hemiarthroplasty for hip fracture.
This was a preliminary, pragmatic, multicentre, parallel group randomized controlled trial in nine secondary and tertiary NHS hospitals in England. Researchers were blinded to group allocation. Overall, 40 trainees in the West Midlands were eligible: 33 agreed to take part and were randomized, five withdrew after randomization, 13 were allocated cadaveric training, and 15 were allocated standard training. The intervention was an additional two-day cadaveric simulation course. The control group received standard on-the-job training. Primary outcome was implant position on the postoperative radiograph: tip-apex distance (mm) (DHS) and leg length discrepancy (mm) (hemiarthroplasty). Secondary clinical outcomes were procedure time, length of hospital stay, acute postoperative complication rate, and 12-month mortality. Procedure-specific secondary outcomes were intraoperative radiation dose (for DHS) and postoperative blood transfusion requirement (hemiarthroplasty).
Eight female (29%) and 20 male trainees (71%), mean age 29.4 years, performed 317 DHS operations and 243 hemiarthroplasties during ten months of follow-up. Primary analysis was a random effect model with surgeon-level fixed effects of patient condition, patient age, and surgeon experience, with a random intercept for surgeon. Under the intention-to-treat principle, for hemiarthroplasty there was better implant position in favour of cadaveric training, measured by leg length discrepancy ≤ 10 mm (odds ratio (OR) 4.08 (95% confidence interval (CI) 1.17 to 14.22); p = 0.027). There were significantly fewer postoperative blood transfusions required in patients undergoing hemiarthroplasty by cadaveric-trained compared to standard-trained surgeons (OR 6.00 (95% CI 1.83 to 19.69); p = 0.003). For DHS, there was no significant between-group difference in implant position as measured by tip-apex distance ≤ 25 mm (OR 6.47 (95% CI 0.97 to 43.05); p = 0.053). No between-group differences were observed for any secondary clinical outcomes.
Trainees randomized to additional cadaveric training performed hip fracture fixation with better implant positioning and fewer postoperative blood transfusions in hemiarthroplasty. This effect, which was previously unknown, may be a consequence of the intervention. Further study is required.
评估对于骨科实习生而言，额外的尸体模拟训练或仅进行标准训练，在接受动力髋螺钉（DHS）固定或半髋关节置换术治疗髋部骨折的患者中，是否能产生更优的放射学和临床结果。
这是一项在英格兰9家二级和三级国民健康服务（NHS）医院进行的初步、实用、多中心、平行组随机对照试验。研究人员对分组情况不知情。总体而言，西米德兰兹郡的40名实习生符合条件：33人同意参与并被随机分组，5人在随机分组后退出，13人被分配接受尸体训练，15人被分配接受标准训练。干预措施为额外的为期两天的尸体模拟课程。对照组接受标准的在职培训。主要结局是术后X线片上的植入物位置：尖顶距离（毫米）（DHS）和肢体长度差异（毫米）（半髋关节置换术）。次要临床结局包括手术时间、住院时间、术后急性并发症发生率和12个月死亡率。特定手术的次要结局是术中辐射剂量（DHS）和术后输血需求（半髋关节置换术）。
8名女性（29%）和20名男性实习生（71%），平均年龄29.4岁，在随访的10个月期间进行了317例DHS手术和243例半髋关节置换术。主要分析是一个随机效应模型，具有患者病情、患者年龄和外科医生经验的外科医生水平固定效应，以及外科医生的随机截距。在意向性分析原则下，对于半髋关节置换术，尸体训练组的植入物位置更好，以肢体长度差异≤１０毫米衡量（优势比（OR）4.08（95%置信区间（CI）1.17至14.22）；p = 0.027）。与接受标准训练的外科医生相比，接受尸体训练的外科医生进行半髋关节置换术的患者术后输血需求显著减少（OR 6.00（95% CI 1.83至19.69）；p = 0.003）。对于DHS，以尖顶距离≤25毫米衡量，组间植入物位置无显著差异（OR 6.47（95% CI 0.97至43.05）；p = 0.053）。在任何次要临床结局方面均未观察到组间差异。
随机接受额外尸体训练的实习生在进行髋部骨折固定时，半髋关节置换术的植入物定位更好，术后输血更少。这种此前未知的效果可能是干预措施的结果。需要进一步研究。
