Evaluating Internal Fixation Skills Using Surgical Simulation

Open reduction and internal fixation (ORIF) is an essential skill for an orthopaedic surgeon, yet teaching its components to surgical residents poses challenges in both complexity and cost. Surgical simulation has demonstrated efficacy and is now a mandated component of residency programs, but the techniques and resources required for effective simulation vary greatly. We hypothesized that simulation of ORIF skills could be accomplished in a cost-effective, quantifiable, and reproducible manner and that this experience coupled with didactic learning would increase skill proficiency and enhance ORIF performance.

Sixteen postgraduate-year-1 orthopaedic surgery interns were assessed on performance of ORIF simulation tasks before and after attending a module designed to introduce and practice internal fixation techniques. Simulation tasks addressed drilling accuracy via oblique drilling through polyvinyl chloride (PVC) cylinders and bisecting wooden dowels and plunge control via drilling through layered boards of varying densities. Fracture fixation simulation involved fixing oblique fractures on synthetic ulnae. Task performance was assessed at 3 time points: immediately before the module, 1 week after the module, and 3 months after the module. Fracture fixation was assessed before and after the module via load-to-failure testing. Success rates for the tasks were analyzed using a repeated-measures analysis of variance, and mechanical properties of the fixed ulnar constructs were compared using paired t tests.

In all ORIF simulation tasks, pre-module to post-module improvement in success rates was significant (p < 0.001) and improvements were maintained between the post-module assessment and the 3-month follow-up. The interns also achieved significantly greater strengths in their ulnar fixation constructs, with a mean improvement of 256 N (p = 0.01) after the module.

These results indicate that the technical and sensorimotor skills relevant to internal fixation (with emphasis on the specific skill of using a drill) can be significantly augmented and retained in the short term in surgical residents after exposure to faculty-led lecture and hands-on skills practice using low-cost materials.

This study provides evidence for an effective, accessible method of enhancing and assessing surgical skills in training.