CORR Synthesis: How Have Film Review and Motion Analysis Been Used to Enhance Orthopaedic Surgical Performance?

In the Beginning… The use of film review, defined as studying footage of oneself or others to improve skills, is common in many professions; it is also frequently used to study athletic performance. Video analysis has been used to determine the match-play demands of different positions in professional rugby [48], and it is frequently used by swimmers to evaluate their performances after competitions [79]. Technological advances have enhanced performance review capabilities. In tennis, the Hawk-Eye player tracking system records player coordinates every 40 ms, and the data collected allow for calculations of speed, acceleration, distance, and direction changes, which provide insight into a player’s style [31]. Motion analysis, defined as the study of motion parameters to improve performance, is also becoming common practice. Small devices can be affixed to athletes to track speed, position, and acceleration data [53, 85]. These data can then be analyzed to gain a more complete understanding of an athlete’s physical capabilities, and this has been used in rugby [27, 29], field hockey [28], Australian football [45, 88], soccer [74], swimming [35], and cross-country skiing [54]. The best athletes in the world are dedicated to training and review their performance with coaches. Similarly, performance review is common in chess, where even the best players review their own games and study the games of other players. Surgery, similar to all endeavors that require accuracy and precision, involves lifelong dedicated practice and learning. Physicians at all stages of their careers, from chief residents to physicians in practice for more than 30 years, have found a film review session with a retired expert surgeon to be productive [42]. In that study, an expert surgeon reviewed the physicians’ surgical footage with them and adjusted the discussion to the experience level of the physician being coached. General surgery residents must complete the Fundamentals of Laparoscopic Surgery and the Fundamentals of Endoscopic Surgery training programs to obtain general surgery certification according to the American Board of Surgery [6]. The residents complete tasks while being graded on precision, efficiency, speed, and accuracy [26, 86]. Although the exact grading metrics are confidential to protect the integrity of the examination, these programs are examples of how validated assessments of surgical skill that correlate with operative performance [60, 80] have been incorporated into surgical training requirements in a nonorthopaedic specialty. Surgeons of all specialties can benefit from advances in technology that allow for refinement of surgical skill. With the advent of unobtrusive motion sensors that give insight into a surgical trainee’s economy of motion [59], orthopaedic surgery training could benefit from these advanced technologies. The Argument Surgical skill historically has been taught using high-volume exposure [34]. Work-hour restrictions have shifted the paradigm, necessitating the creation of more formal and efficient surgical curricula to ensure surgeons finish training with high levels of proficiency despite fewer hours of experience. The American Board of Orthopaedic Surgeons refers to this as a “transition from time-based programs for the acquisition of knowledge and skills to promoting competency-based curricula” [4]. The coronavirus-19 pandemic has also decreased surgical procedure volume for orthopaedic residents, which further emphasizes the need for better methods of teaching surgical skill [37]. Programs have reported various competency-based, novel methods of teaching such as the “surgical games,” in which residents complete simulated tasks, such as a cadaveric carpal tunnel release or a Sawbones model TKA, under direct observation by attending surgeons [16]. Although individual studies such as this have been successful, the cost and time requirements associated with a transition to competency-based curricula seen in countries outside the United States have resulted in concerns that full-fledged adoption of this educational approach will overburden American facilities [22]. Standardized video review and motion analysis could ease this burden. Direct observation requires faculty surgeons to be present to grade the trainee, which can be time prohibitive and therefore unrealistic as a longitudinal training method in which skill progression is tracked. Motion analysis would be especially useful in an orthopaedic training setting because data can be processed and presented rapidly without the need for faculty to be present. Film review is also an efficient training tool because hours of footage can be condensed by nonmedical staff so only pertinent parts of the procedure are included for surgeon and trainee review. Furthermore, blinded film review and motion analysis enable an objective, unbiased assessment of trainees. Orthopaedic surgery training is slowly catching up to athletic training in its use of technology to measure performance, but there is still no standardized curriculum that includes video review and motion analysis with set benchmarks for surgical skill acquisition. Rapid curriculum changes risk being expensive and ineffective [22], and the evidence regarding implementation of film review and motion analysis into orthopaedic training is not all positive. Of the few randomized controlled trials assessing the effect of augmenting surgical learning with film review, most showed no improvements relative to conventional learning methods [8, 9, 21]. In contrast, when film review and motion analysis are used to assess trainees, there are many observational studies that demonstrate the efficacy of these tools in differentiating between experience levels and tracking learning curves, with the caveat that not all motion parameters can represent orthopaedic skill. This review will examine how film review and motion analysis have been used in orthopaedics. Essential Elements We performed this review via detailed, standardized searches of PubMed and Embase through May 30, 2022 (Supplemental Table 1; https://links.lww.com/CORR/A997). We searched for original, prospective (randomized and nonrandomized) or cross-sectional studies that evaluated or relied on the use of film review or motion analysis in orthopaedic surgical training. Searches were not limited by language. We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses–styled search process to go through the search return [66]. Screening was performed using the Endnote library (ENDNOTE 20, Clarivate). We combined the PubMed and Embase search results for motion analysis and film review. After screening for duplicates, there were 973 studies. We excluded 781 studies through abstract review because they were not relevant to the topic. These excluded studies included but were not limited to topics such as the use of instructional didactic videos for orthopaedic trainees, videos for patients before or after orthopaedic procedures, and the use of motion technologies to assess postoperative outcomes. We included studies that examined the use of film review or motion analysis to directly enhance or measure surgical performance or procedural learning curves, in which participants were students in their first year of orthopaedic residency or later in their orthopaedic career. We excluded studies if medical students were the only participants being tested, but we included studies that had medical students as a novice group to compare with orthopaedic residents. We included high-quality studies using cadavers or simulators. Studies examining procedures frequently performed by orthopaedic residents but in which orthopaedic residents were not the participants in the study were included. For instance, a study of plastic surgery residents performing carpal tunnel releases in which some of the video reviewers were orthopaedic surgeons was included. We excluded case series, case reports, systematic reviews, and expert opinion articles. We excluded studies in which film review or motion analysis was solely used to grade trainees, and in which the efficacy of these grading measures was not being examined. After full-text review, we included 27 studies investigating the use of film review in orthopaedics including five randomized controlled trials [8, 9, 21, 36, 47] and 22 observational studies [3, 11, 12, 15, 20, 23, 24, 30, 41, 44, 50-52, 56, 61, 64, 65, 69, 77, 78, 81, 82]. We included 28 studies investigating the use of motion analysis in orthopaedics, including four randomized controlled trials [40, 58, 62, 70] and 24 observational studies [2, 7, 13, 14, 17, 18, 32, 38, 39, 43, 49, 57, 63, 67, 68, 71-73, 75, 76, 83, 84, 89, 90]. We assessed the quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations criteria, which assesses the quality of evidence for each outcome [33] (Supplemental Table 2; https://links.lww.com/CORR/A998). Based on this assessment, seven randomized controlled trials [8, 9, 21, 36, 47, 58, 62] contributed moderate-quality evidence while all observational studies and two randomized controlled trials [40, 70] contributed very low–quality evidence. The quality of evidence was downgraded for several reasons, most commonly for small sample size and inconsistency of results between studies. What We (Think) We Know Does Film Review Enhance Learning? Although junior residents often find film review sessions with more experienced surgeons useful [44], learning augmented with film review had no objective effect on resident learning relative to conventional learning methods for performance on a fracture reduction simulation [21], simulated vascular anastomosis [9], or plating and tension band wiring of surgical model fractures [8]. In contrast to these findings, reviewing surgical microscope footage with an expert surgeon enhanced early learning for neurosurgical residents performing lumbar spine procedures in the operating room, although the conventional-learning students eventually reached the same performance level [36]. Evidence more strongly in favor of supplementing conventional learning with film review also exists. 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