Trainees in orthopedic surgery are required to receive dedicated laboratory-based surgical skills training in their first year of residency. Simulators are often used in this training. Our group previously developed a hip fracture wire navigation simulator to train and assess skill in placing a K-wire within a femur bone surrogate using synthetic fluoroscopic images to aid in navigation. In this paper, we describe design considerations and challenges in modifying the existing simulator to enable the training of multi-wire pinning of a pediatric supracondylar humerus fracture. The design involves changing the bone of interest from the adult femur to the pediatric humerus, while using the same platform technology. Considerations include ease of use, minimizing motion of the fixed bone, and minimizing materials used. The robustness of the bone mounting was tested by running an experiment using 3D scans and surface deviation analysis to test repeatability of bone placement and its resistance to rotational motion after being placed in the fixture. After the new design was shown to hold the bone rigidly, a pilot study of the new simulator was conducted to confirm that the surgeons and residents consider the simulator experience as being a valid representation of the actual surgical skill.

Orthopaedic resident training has been, and continues to be, in a state of flux. Initially, there were limits placed on the number of hours a resident could work in a week [1]. Later, residency programs were required to provide laboratory-based training in basic surgical skill for first year residents [2]. Now there is a push towards a competency-based training program that graduates residents who demonstrate their acquisition of adequate surgical skills [3]. With each of these shifts in the training model, programs and institutions have looked increasingly to simulation-based training to ease the way. Simulation offers opportunities to train surgeons quickly, provide essential feedback to foster improvement, and assess skill acquisition. With the broad swath of requirements to satisfy in orthopaedic surgical skills training, a simulation platform must support an array of training capabilities for resident practice and performance assessment. Wire navigation is a central skill in orthopaedics that has a broad variety of applications. In this task, surgeons must use 2D intra-operative fluoroscopic images to visualize the 3D anatomy of a patient and place a wire along a specified path through bone. In some situations, placing the wire is the final task; in others the wire serves as a guide for subsequently placed cannulated implants. Regardless of the situation, the placement of the wire in the bone directly influences the surgical result for the patient. We previously presented the design of a wire navigation surgical simulator dedicated specifically to hip wire navigation [4]. Our experience with the dozens of surgeons and residents who have used the simulator suggest that they find the general skill of guiding a wire to be relatively abstract. They are more drawn to practicing specific surgeries rather than the general skill. To address this need, we have modified the simulator to present new surgical procedures, while still exercising the underlying skill of wire navigation. We also learned that the task of directing the fluoroscope in order to acquire appropriate view angles for making surgical decisions is integral to surgical wire navigation, so we extended the simulator to include this important aspect of surgical skill.