title: Training effect of using Touch Surgery for intramedullary femoral nailing.
abstract: BACKGROUND
  Simulation in orthopaedic training is becoming increasingly popular and has been widely used in formal curricula. However, these resources are expensive and not easily accessible to every trainee. Other means of disseminating surgical education through virtual reality (VR) multimedia can act as useful adjunct to traditional methods of teaching. One validated VR platform is Touch Surgery, a cognitive task simulation and rehearsal app.
  
  
  OBJECTIVE
  The primary objective of this study was to identify the training effect of Touch Surgery intramedullary femoral nailing (IFN) modules using objective performance metrics over six consecutive attempts. Secondary objectives consisted of validated multiple choice questions (MCQ) testing before the first (pre) and after the sixth (post) attempts.
  
  
  METHODS
  27 medical undergraduates were recruited to complete the decision-making process six consecutive times for four modules on the procedural steps of IFN. The modules consisted of (i) preparing the patient and equipment, (ii) femoral canal preparation, (iii) nail insertion and proximal locking, and (iv) distal locking and closure. Real-time objective performance metrics were obtained, stored electronically and analysed using the median and Bonett-Price 95% confidence intervals from the participants' attempts to assess training effect. Significance was calculated using the Mann-Whitney U test for independent data whilst the Wilcoxon signed ranked test was used for paired data. Significance was set as 2-tailed p-value <0.05.
  
  
  RESULTS
  Median performance scores per attempt for all four modules demonstrated a significant improvement ranging from 58 to 115%. Scoring variability and distribution was reduced and more predictable per attempt. Logarithmic learning curves elicited strong positive correlations between the number of attempts and scoring. Mean scores for pre and post-study MCQs tests significantly improved from 83 to 94% in all modules.
  
  
  CONCLUSIONS
  IFN modules on Touch Surgery app demonstrated a significant training effect with practice. Novices demonstrated cognitive competencies to ensure patient safety prior to operating. The app is an effective adjunct to traditional learning methods and has the potential for curricular implementation.
authors.affiliation: MSk Lab, Imperial College London, Level 7 East, Charing Cross Hospital, Fulham, London W6 8RF, UK. Electronic address: ks704@ic.ac.uk.
authors.forename: Kapil
authors.initials: K
authors.lastname: Sugand
authors.affiliation: MSk Lab, Imperial College London, Level 7 East, Charing Cross Hospital, Fulham, London W6 8RF, UK. Electronic address: mala.mawkin13@imperial.ac.uk.
authors.forename: Mala
authors.initials: M
authors.lastname: Mawkin
authors.affiliation: MSk Lab, Imperial College London, Level 7 East, Charing Cross Hospital, Fulham, London W6 8RF, UK. Electronic address: c.gupte00@ic.ac.uk.
authors.forename: Chinmay
authors.initials: C
authors.lastname: Gupte
mesh_terms: D001842:Bone and Bones / Q000033:anatomy & histology / Q000601:surgery*; D002983:Clinical Competence / Q000592:standards*; D003198:Computer Simulation; D004504:Education, Medical, Undergraduate; D005260:Female; D005264:Femoral Fractures / Q000601:surgery*; D005594:Fracture Fixation, Intramedullary / Q000193:education* / Q000379:methods; D006801:Humans; D059032:Learning Curve; D008297:Male; D009985:Orthopedics / Q000193:education*; D015203:Reproducibility of Results; D011795:Surveys and Questionnaires; D006113:United Kingdom; D014584:User-Computer Interface; D055815:Young Adult
keywords: Intramedullary femoral nailing; Simulation; Surgical training; Touch Surgery; Trauma and orthopaedics; Virtual reality