Training With Ao Digital Enhanced Hands-on Surgical Training (Dehst) Improves the Proficiency Level of Novices in Distal Intramedullary Nail Interlocking

The outcome of orthopaedic and trauma surgery depends to a considerable extent on the surgeon's skills and level of training. Practical exercises are an essential pillar of a comprehensive training concept to improve surgical skills. A novel Digitally Enhanced Hands-on Surgical Training (DEHST) platform was introduced to train relevant practical skills in a safe and radiation-free environment. DEHST is a modular, transportable, cost-effective surgical skills training platform and features a proportionally reduced model of a simulated intraoperative image intensifier with an artificial X-ray engine simulating radiation-free X-ray images. A DEHST training module was developed to overcome the lack of training capabilities for the challenging task of freehand distal interlocking of intramedullary nails. The aim of this study was to evaluate the proficiency level of novices in distal intramedullary nail interlocking achieved through training with DEHST. Ten novices (group DEHST) underwent five DEHST training sessions (approximately one hour in total). Surgical performance metrics such as the time taken, number of X-rays, accuracy of nail hole roundness, and success rates were obtained during a simulated distal interlocking operation using a real image intensifier and a real tibia nail in an artificial bone model. Outcomes were compared with surgical performance of novices without DEHST training (group novices, n=10) and against surgical experts (group expert, n=10) performing the same simulated operation. The DEHST group achieved a higher success rate (90% vs. 60%) and significant better performance in terms of time (414.7 s vs. 623.4 s, p = 0.041), hole roundness (95.0% vs. 80.8%, p < 0.001) compared to the novice group. A comparable performance to the expert group was observed for the number of X-rays (26.0 vs. 22.5, p = 0.281), and accuracy of hole roundness (95.0% vs 93.3%, p = 0.087). However, the participants in the DEHST group needed significantly longer time compared to the experts (414.7 s vs. 256.1 s, p = 0.001), and additionally, one participant (10%) failed to hit the nail hole with the drill bit, while 100% of the expert group were successful. DEHST has shown to be a useful tool to improve the proficiency level of novices and to train relevant practical surgical skills needed for distal interlocking of intramedullary nails. However, further investigations are needed to demonstrate the performance under the conditions of a real operation.