Introduction: Simulation based education and training is most effective when simulated modules mirror real life scenarios. In surgical training, surgical skill acquisition occurs for surgical trainees intraoperatively; in the presence of a supervising consultant to provide guidance and oversight on the procedure. While simulation based surgical training tools have been demonstrated to accelerate technical surgical skills, the relationship between human factors and trainee performance including the impact of supervision on trainee stress and practical skill acquisition not well established. This was an interventional comparative study to evaluate the impact of consultant supervision on surgical trainee simulated surgical performance and stress levels.
Methods: Orthopaedic doctors from a regional hospital were invited to participate, and asked to complete a simulated proximal femoral nail module both with and without direct consultant supervision. Participants wore a heart rate monitor during the task to assess heart rate variability. Performance was assessed using validated simulator based metrics. Variations in heart rate were analysed for correlation with task stage and any errors made during the procedure.
Results: Sixteen participants were included for analysis. Max heart rate recorded while under direct supervision was significantly higher (p=0.002) than unsupervised recorded rates. A positive correlation between increased heart rate and consultant questions was demonstrated. No significant difference in performance in the presence of consultant supervision was noted.
Conclusion: Consultant supervision resulted in higher surrogate stress markers with no significant improved performance. The impact of non-technical factors on trainee performance should be considered in future surgical training curricula.

Introduction: The introduction of minimally invasive surgery (MIS) resulted in a paradigm shift in the surgical skillset, with adaptation of the surgical training scheme required to reflect this. Development of incorporated surgical simulation based training is an area of burgeoning interest in orthopaedics, with MIS skills reported to transfer well from the virtual platform. Performance demonstrated in expert and novice surgeons in simulated procedures has been previously evaluated to identify markers to gauge trainee skill levels, however a dearth of research exists on the acquisition of ambidexterity conferred by experience in the use of arthroscopic techniques.
Methods: A prospective comparative study was carried out across three regional units. Participants were divided into novice, intermediate or experienced groups based on arthroscopic experience. Baseline demographics including age, sex, handedness and gaming history were also collected. Participants were asked to complete a simulated task requiring bimanual control consisting of visualisation and manipulation of outlined objects twice, with one attempt for manipulation per hand collected for analysis.
Results: Fifty-six participants were included for analysis. The novice group demonstrated significantly superior grasper efficiency in their dominant hand performance compared to their non-dominant attempt (p=0.01). No significant difference was noted between dominant and non-dominant hands in the experienced group. Significant heterogeneity in camera alignment skills was demonstrated between hands in all groups.
Conclusion: Ambidexterity is a skill required in many surgical approaches. Skilled bimanual control confers innumerable advantages to the surgeon, warranting dedicated training modules to be included in surgical training curricula.

Mixed reality (MR) is a concept developed for use with computer-glasses that are equipped with cameras and sensors. MR allows the surgeon to have access peri-operatively to relevant patient information, the surgical technique (displayed holographically if desired) and also to interact with individuals outside of the operating theatre. The objective of this study was to evaluate the experience of MR in a cohort of trauma and orthopaedic surgeons across different countries and cultures. Methods; A consecutive series of 13 orthopaedic surgeries (shoulder, hip, knee, and spine) were performed involving surgeons from 13 different countries. For each intervention the surgical team utilised an MR system connected to both patient data in a holographic format and two other surgeons located in different countries. An electronic questionnaire was subsequently sent to all participating surgeons to asses their experience of the MR technology. Questions were posed in the format of a Likert scale. Results; The level of satisfaction with the MR system was rated good or excellent by all the respondents. Satisfaction was highest with functions of communication, followed by access to holographic patient data and pre-operative planning. The principle difficulties reported by respondents were related to the quality of local WIFI services, and the subsequent need to use applications sequentially rather than simultaneously. Discussion; This was to our knowledge the first international multicentre evaluation of surgeon satisfaction with MR technology in orthopaedic surgery. This technology also has significant potential to be a useful modality in augmenting current capabilities with respect to computer navigation.

INTRODUCTION: Delayed Union and non union of long bones has always been a challenge to address. Not many alternatives other than re-osteosynthesis, ring fixators +/- bone grating, bone substitutes are available. METHODS: We audited patients that underwent Exogen LIPUS treatment at our hospital. Clinical and & Radiological Outcomes of EXOGEN ultrasound bone healing system in management of patients with delayed unions and non unions was assessed. We excluded patients who dropped out prior to completion. The cohort was 11 patients,
Time period – Jan 2018 - 2019 (12 months) and all the patients underwent 250 Exogen Module ( 250 doses max.) 20 minutes /day. Patient compliance was measured and only the ones with 95% compliance were included in the study. RESULTS: Patients were assessed clinically and radiologically. 8/11 patients had clinical and radiological union – 72.7% (5 non unions and 3 delayed unions), Failed 3/11 - 27.2%. Patients who failed to achieve union underwent re-osteosynthesis with autologus bone graft. Literature mentions of an average 55-63% union rate in established Non unions. In our series we had 72.7% healed Vs 27.2% Failed. DISCUSSION & CONCLUSIONS: EXOGEN ultrasound bone healing system can be used for long bone fractures with non-union or delayed healing. We believe that its a good option before attempting Re-osteosynthesis and would require senior clinicians judgement.
Cost saving of £2,407 per patient compared with current management, through avoiding surgery.We conclude that use of EXOGEN is a good cost effective/ non invasive option to implement for long bone non unions.

Introduction: In recent years, computer assisted surgery (CAS) has made it possible to undergo surgery with a high degree of precision. The aim of this study was to investigate the usefulness of CAS for femoral trochanteric fractures using the ADAPT (ADAPTIVE POSITIONING TECHNOLOGY) system.
Methods: A total of 40 patients with a femoral trochanteric fracture underwent intramedullary nailing for fracture fixation: in 20 patients the ADAPT system (ADAPT group), in 20 it was not used (Control group). The position of the lag screw within the femoral head and neck was evaluated using post-operative X-rays and computed tomography (CT) scans. We measured the operative time, intraoperative fluoroscopy time, tip-apex distance (TAD), and tip-to-head-surface distance (TSD) were assessed.
Results: The operative time was significantly shorter in the ADAPT group (P<0.05). Intraoperative fluoroscopy time was significantly reduced in the ADAPT group (P<0.01), and implant placement was significantly better in the ADAPT group (P<0.01).
Conclusion: Navigation systems have been developed to improve the efficiency of surgery, and the ADAPT system was considered to be a very useful device for intramedullary nailing of femoral trochanteric fractures.

Background: Traditional methods of surgical training typically involves training in an operating theatre under the supervision of senior surgeons; however, this has become challenging due to increasing costs, decreasing resident work hours and patient safety. Virtual Reality (VR) simulators have recently emerged as a possible method to allow patients to practice and hone their surgical skills outside the operating theatre. Methods: We used the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) algorithm to systematically screen and select studies from four databases: Embase (via Ovid), PubMed, Web of Science and Scopus. Studies were eligible if they investigated the effectiveness of VR training for femoral nail procedures. Risk of bias was assessed using the Cochrane Risk of Bias in Non-Randomised Studies of Interventions (ROBINS-I) checklist. Results: Fifty studies were identified following our database search. Four studies met the eligibility criteria, comprising a total of 86 participants. Outcome measures displayed significant heterogeneity (17 different outcome measures used). A subjective analysis across all studies showed that VR training for the femoral nail application procedure demonstrated face, content, construct and transfer validity. Conclusion: VR simulation training for femoral nail applications has shown significant benefits to psychomotor and cognitive skills in students and orthopaedic trainees. VR simulators provide a realistic and cost-effective opportunity for trainees to practice their surgical skills, without having to rely on theatre-based experience. This is of particular importance during the COVID-19 pandemic where elective procedures have been cancelled at short notice, limiting surgical exposure for trainees.

Introduction: Cut-out of hip screws after fracture fixation has been quoted as 8% in the literature. The tip-apex distance (TAD) is the strongest predictor for cut-out after operative fracture stabilisation.
The aim of this study was to evaluate the ADAPT system (Adaptive Positioning Technology, Stryker, USA), a navigation device for intramedullary nailing of trochanteric fractures and its effect on optimising the TAD. This is the first clinical study to evaluate this new technology.
Methods: The study group of 36 consecutive patients with a pertrochanteric fracture underwent intramedullary nailing for fracture fixation using ADAPT technology, while the matched-control group underwent conventional Gamma-3-nailing. Matching criteria included fracture-classification, gender and age. We measured the operative-time and the postoperative TAD in anteroposterior (AP) and lateral radiographs of the 72 patients.
Results: The mean TAD using ADAPT was 16.9 mm (range 8.4–33.7 mm) compared with 24.9 mm (range 14.6–40.2 mm) in the reference group treated without ADAPT. Using the ADAPT system significantly improved (p < 0.0005) the accuracy of lag screw placement but had no effect on operating time in fixation of femoral pertrochanteric fractures.
Conclusion: Working with the ADAPT system for positioning the lag screw using the Gamma-3-nail led to a statistically highly significant reduction of the TAD compared to the reference group (p < 0.001). The ADAPT system proved to be a very useful device in achieving higher surgical standards for the treatment of trochanteric fractures with intramedullary nailing. It enables higher accuracy in screw positioning and therefore better placement of the implant.