This module allows medical officers and surgeons who are not orthopedic specialists to become confident and competent in irrigation and debridement, powered and manual drilling, positioning and correctly inserting Schanz screws, and constructing the uniplanar external fixator frame as part of external fixation procedures for open tibial shaft fractures performed in regions without specialist coverage. To maximize patient safety, this module teaches learners to use a powered drill to insert self-drilling Schanz screws through the near cortex and then manually advance Schanz screws into the far cortex to avoid plunging.
Lessons Learned[edit | edit source]
We provide information on how lessons learnt from the development of our original prototype surgical module have been used in the development of this additional sub-module.
Development of Simulator[edit | edit source]
We provide information on how lessons learnt from the development of our original prototype surgical module have been used in the development of the simulator for this additional sub-module.
After the August 25-26, 2022 site visit during which we received feedback that "the instructions for 3D bone printing are producing inconsistent results across different sites," our team substantially revised and simplified our simulator build instructions by eliciting feedback from workshop attendees at this year’s Bali Fab Fest and 10 3D printing organizations in 7 countries, including 3 LMICs. Our simulator build instructions now include on one centralized Appropedia page:
- Pre-tested, ready-to-print files for 4 brands of 3D printers available in LMICs;
- Quick Start Guide for preparing print files for experienced 3D printer users;
- Checklist for Required Print Settings with screenshots of settings;
- Quality Assurance Checklist with instructions and screenshots on how to correct print settings for observed printing errors;
- Troubleshooting Guide link to detailed step-by-step instructions on 7 Appropedia pages for novice 3D printer users and which includes explanations on why print settings cannot be modified; and
- Pricing Quotes from 3 LMICs.
Based on feedback from Dr. Catherine Mohr and Dr. Adam Kushner on August 25, 2022, we considered adding a diamond-shaped screw insertion hole in the vise attachment of the Tibial Shaft Transverse Fracture Simulator to print support-free and to permit learners to secure the bone models to the side of a table if there are no vise clamps available. On September 8, 2022, we conducted testing in Abuja and showed that an orthopedic surgical drill and drill bit could be used to drill two holes in the vise attachment of each bone model and two nails can inserted through the holes of the vise attachment and into the side of a wood board to secure the bone model to a table.
We made the following observations:
- The vise attachment of the 3D printed bone model can tolerate drilling with a standard drill bit and insertion of two nails without mechanical failure. To prevent splintering of the wood board, the holes should be drilled into the center of the side of the wood board. Thus, we did not create diamond-shaped screw insertion holes into the vise attachment because the position of the holes will vary depending on the thickness of locally available wood boards.
- The dome base of each model should be used to support the model on the table.
- Two nails are required to be inserted into the vise attachment to prevent displacement of the bone model during drilling. A hammer is not required. Any suitable heavy implement can be used to apply mechanical force to insert the nails.
- Removing one nail from the vise attachment of the distal fragment will permit displacement of the fracture for simulation skills training.
We have now revised and updated our simulator build instructions to empower learners to practise on our simulators without vise clamps which helps minimize their training equipment costs.
Development of Educational Material[edit | edit source]
We provide information on how lessons learnt from the development of our original prototype surgical module have been used in the development of the educational material for this additional sub-module.
Based on the external evaluator feedback shared by Dr. Catherine Mohr on August 24, 2022, we included a link to a 5 second video segment on how to insert a chuck key into the drill in the skills training page.
- On August 29, 2022, we created and uploaded two short Youtube videos on how to manually rotate the chuck with T-handle to tighten and loosen the jaws of the chuck over the Schanz screw in Step 5 of the skills training page. On September 12, 2022, we uploaded new videos and corrected the instructions (in italics) to manually rotating the proximal part of the chuck clockwise to tighten the chuck over each Schanz screw and manually rotating the proximal part of the chuck anticlockwise to loosen the chuck over each Schanz screw.
- On September 10, 2022, we filmed videos on how to insert the chuck key into the chuck with T-handle to tighten or loosen the jaws of the chuck over the Schanz screw to include in Step 5 of the skills training page. These videos were uploaded to Youtube on September 12, 2022.
- Our skills training video was shot and edited to showcase how to use a friction or keyed chuck and we included the Arbutus Medical HEX Drill instructional video link to familiarise learners with using drills.
Development of Self-Assessment Framework[edit | edit source]
We provide information on how lessons learnt from the development of our original prototype surgical module have been used in the self-assessment portion of this additional sub-module.
Based on external evaluator feedback shared by Mr. Daniel Berman on August 25, 2022, we started researching additional points of assessment to possibly add and asked our RCSI Mentor, Mr. Eric O'Flynn to please connect us with RCSI experts who can help us brainstorm additional suitable points of assessment. On September 8, 2022, we asked Mr. Eric O'Flynn, our RCSI mentor, to approach Mr. Daniel Berman at Challenge Works to see if he could provide more specific feedback from the external evaluation partner to help identify a suitable SME to assist with this feedback request. On September 20, 2022, Mr. O'Flynn informed us that Mr. Berman stated he had no more information or insight than “they suggested having more assessment items.” We added total procedural time which indirectly measures confidence and likely measures competence in conjunction with the checklist and photo review.
Acknowledgements[edit | edit source]
This work is funded by a grant from the Intuitive Foundation. Any research, findings, conclusions, or recommendations expressed in this work are those of the author(s), and not of the Intuitive Foundation.