title: Surgical process analysis identifies lack of connectivity between sequential fluoroscopic 2D alignment as a critical impediment in femoral intramedullary nailing.
abstract: OBJECTIVE
  Identifying key steps and barriers within complex and simple surgical procedures can be accomplished in a structured and rigorous manner using surgical process modeling. For lower extremity long bone fracture stabilization, the current standard of care is closed intramedullary (IM) nailing, which, despite its widespread use, is associated with challenges that greatly impact operative time and lead to the frustration of medical staff. The aim of this study was to identify challenging surgical steps in IM nailing and understand their underlying causation.
  
  
  METHODS
  Eight semi-structured interviews with staff orthopedic surgeons and eight detailed surgical observations were conducted to understand the surgical steps, challenges and adapted techniques used in IM nailing. Hierarchical decomposition was then utilized to structure the IM nailing surgical procedure into phases, steps and activities.
  
  
  RESULTS
  In the developed IM nailing surgical process model, the most challenging steps were identified as fracture reduction (75%) and entry point selection (25%), both of which were associated with high levels of frustration in the observed surgeries. Both of these steps utilize 2D fluoroscopic imaging to guide 3D alignment. Challenges arise when the alignment in one plane is lost while adjusting the alignment in the perpendicular plane. This leads to unpredictable repetition of activities which can be time-consuming and frustrating.
  
  
  CONCLUSIONS
  Identifying the causation of surgical challenges in IM nailing through surgical process modeling forms a knowledge base that can be used to guide future improvements to techniques and surgical instrumentation.
authors.affiliation: Holland Musculoskeletal Program, Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.|Institute of Biomaterials and Biomedical Engineering, University of Toronto, Rosebrugh Building, Room 407, 164 College Street, Toronto, ON, M5S 3G9, Canada.
authors.forename: Hamid
authors.initials: H
authors.lastname: Ebrahimi
authors.affiliation: Holland Musculoskeletal Program, Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.|Institute of Biomaterials and Biomedical Engineering, University of Toronto, Rosebrugh Building, Room 407, 164 College Street, Toronto, ON, M5S 3G9, Canada.|Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, 149 College Street, 5th Floor, Toronto, ON, M5T 1P5, Canada.
authors.forename: Albert
authors.initials: A
authors.lastname: Yee
authors.affiliation: Holland Musculoskeletal Program, Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada. Cari.whyne@sunnybrook.ca.|Institute of Biomaterials and Biomedical Engineering, University of Toronto, Rosebrugh Building, Room 407, 164 College Street, Toronto, ON, M5S 3G9, Canada. Cari.whyne@sunnybrook.ca.|Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, 149 College Street, 5th Floor, Toronto, ON, M5T 1P5, Canada. Cari.whyne@sunnybrook.ca.
authors.forename: Cari
authors.initials: C
authors.lastname: Whyne
mesh_terms: D000465:Algorithms; D005264:Femoral Fractures / Q000000981:diagnostic imaging / Q000601:surgery*; D005471:Fluoroscopy / Q000379:methods*; D005594:Fracture Fixation, Intramedullary / Q000379:methods*; D006801:Humans; D008953:Models, Anatomic; D025321:Surgery, Computer-Assisted / Q000379:methods*
keywords: Entry point selection; Hierarchical decomposition; Intramedullary nailing; Reduction; Sequential fluoroscopic 2D alignment; Surgical process modeling