Study DesignModified Delphi study.ObjectivesTelementoring, the practice of providing remote guidance and teaching from a distance using telecommunication technology, has demonstrated feasibility and value in assisting surgeons in remote locations. However, limited evidence exists regarding its effectiveness in improving surgeon performance. This study aimed to develop metrics to assess spine surgeon performance in scoliosis surgery, potentially within the context of a telementoring training program.MethodsTen expert spine surgeons participated in a four-round modified Delphi process including both online and in-person meetings. The resulting metrics were validated for objective assessment by eleven surgeons, who reviewed and rated a video recording using the established rubric.ResultsThe final set of metrics, comprising 50 procedural steps and 28 error categories, was unanimously approved by the panel. Additionally, the panel agreed that utilizing cameras, smart lenses, and output from intraoperative imaging monitors would provide sufficient visibility for assessing both steps and errors.ConclusionsA set of assessment metrics for adolescent idiopathic scoliosis surgery was successfully defined and validated by reviewing example videos. The longer-term research objective is to employ this rubric to assess surgeon's performance throughout a telementoring program, thus assessing its educational impact. The rubric could also be used in other contexts, such as live surgical observation.

Background A critical step in curriculum development is conducting a needs assessment of learners. In spine surgery, the educational needs of trainees, and especially of practicing surgeons, evolve frequently due to changes in practice, technology, etc. To monitor these changes and adapt the educational offerings, organizations delivering continuing medical education (CME) and continuing professional development (CPD) periodically repeat needs assessments. Methods An international needs assessment in the form of a set of 15 online questions was designed and circulated in 2017 and in 2021 to the AO Spine community of members and registered users to gather input in five main areas: educational needs in spine pathologies and techniques, required improvements in practice, preferences for types of educational offerings, and profiling information. Results We received and analyzed 1,204 responses in English during the main reporting period in the 2017 needs assessment from residents, fellows, and practicing surgeons in orthopedics and neurosurgery, and 1,845 in 2021. Spine surgeons wish to improve their knowledge related to all the common pathologies, with some variability among regions and stage of career. Minimally invasive spine surgery (MISS) was the highest-rated need within surgical techniques in all regions (except North America) and all stages of career. Data show a strong preference for face-to-face courses with hands-on training, high demand for mentorship/fellowship/observership, and solid interest in online and blended education. Conclusions The needs assessment process pointed out general trends but also identified varying needs depending on the local situation and stage of career. For this reason, CME/CPD providers must adapt to the local situation to provide educational offerings that meet learner needs.

COVID-19 pandemic created a need to improvise and redefine blended learning to be executed fully online. Background information on the effectiveness of fully online blended learning activities, especially for surgical disciplines is limited. This study describes a fully online blended learning course format on spinal surgery and aims to provide data regarding it effectiveness. Fully online blended courses on three topics of spinal surgery designed as six-week asynchronous and followed by 3-day live parts. Learning gaps (LGs) were identified with a survey at the beginning of asynchronous part, at its end, and at the end of the live part. The effectiveness of the asynchronous and live parts was assessed by LGs and a quiz, login statistics of learners and faculty and a post-course survey. Participants' LGs decreased in all courses, statistically significant in two. Faculty and learner login rates significantly correlated with each other. Faculty and learner satisfaction was very high. A fully online blended learning course can be delivered effectively on spine surgery with a high participant and faculty satisfaction rate. The asynchronous part contributes to learning significantly.

Skills training is important in an arthroplasty curriculum and can focus either on "part tasks" or on full procedures. The most commonly used simulations in orthopedics including arthroplasty are anatomic specimens, dry bone models, and virtual or other technology-enhanced systems. A course curriculum planning committee must identify the gaps to address, define what learners need to be able to do, and select the most appropriate simulation modality and assessment for delivery. Each simulation must have a clear structure with learning objectives, steps, and take-home messages. Feedback from learners and faculty must be integrated to improve processes and models for future learning.

Small group discussion (SGD) is a well-known educational method to promote active learning. Best practices for running SGDs in face-to-face events are described in the literature; however, little has been reported regarding synchronous online delivery. The aim of this study was to determine learner and instructor preferences for online SGDs in terms of group size and composition and to formulate best practices based on participant and faculty feedback. We designed an 8-module online course for surgeons managing upper extremity trauma. Participants were pre-assigned into 2 types of group: 1 faculty with 5 participants or 2 faculty with 8 participants. We collected feedback from 91 participants and 34 faculty over the 8 weeks in multiple ways. Participants preferred way to run an online SGD is to have 2 faculty with 4-5 participants (80%), rotating to different faculty every week (67%), and interacting with peers from different countries (95%). Pre-course assessment questions and pre-recorded presentations enhanced the online discussions for 82%. From open text comments, we identified that cases/content, faculty, participant engagement, and technical support worked well. The course could be improved by adding more extensive technical and connectivity checks, having a different time scheduling, and integrating more supporting materials.

Introduction: Although intraoperative imaging is important for assessing the quality of several steps during fracture fixation, most trainees and surgeons have received little formal education on this topic and report they learn "on the job" and "through practice". A planning committee of orthopedic trauma surgeons was established to design a curriculum using "backward planning" to identify patient problems, identify gaps in surgeons' knowledge and skills, and define competencies as a framework for education in order to optimize patient care. Materials and methods: The committee defined 8 competencies related to intraoperative imaging, with detailed learning objectives for each one (e.g. select the imaging modality, set up the operating room). An interactive, case-based half-day seminar to deliver these objectives for 2-D and 3-D intraoperative imaging during the fixation of common fractures was designed. The seminar was delivered in several locations worldwide over a 6-year period and evaluation and assessment data were gathered online. A full-day procedures course was added and delivered 6 times to address the skills component of competencies. Results: 17 seminars and 6 courses were delivered and attended by an average of 26 and 17 participants respectively (ranges 13-42 and 13-20). Pre-event gap analysis and assessment question scores confirmed needs and motivation to learn in all events. 97% of the 442 seminar participants and 98% of the 100 course participants would recommend the events to colleagues. An average of 88% and 90% respectively learned something new and plan to use it in their practice (range 63%-100%). Commitment to change (CTC) statements showed intended practice improvements related to all competencies. Discussion: The large percentages of high impact ratings for all events suggest the content met the needs of many participants. Post-event reduction in gap scores and an increase in the desired level of ability for most competencies suggests the content addressed many gaps. Conclusions: Case-based, interactive seminars and courses addressing knowledge, skills, and attitudes to optimize the use of intraoperative imaging during the fixation of common fractures help address unmet educational needs for trainees and complements existing formal training. (C) 2021 Elsevier Ltd. All rights reserved.

To examine how to optimise the integration of multiple-choice questions (MCQs) for learning in continuing professional development (CPD) events in surgery, we implemented and evaluated two methods in two subspecialities over multiple years. The same 12 MCQs were administered pre- and post-event in 66 facial trauma courses. Two different sets of 10 MCQs were administered pre- and post-event in 21 small animal fracture courses. We performed standard psychometric tests on responses from participants who completed both the pre- and post-event assessment. The average difficulty index pre-course was 57% with a discrimination index of 0.20 for small animal fractures and 53% with a discrimination index of 0.15 for facial trauma. For the majority of the individual MCQs, the scores were between 30%-70% and the discrimination index was >0.10. The difficulty index post-course increased in both groups (to 75% and 62%). The pre-course MCQs resulted in an average score in the expected range for both formats suggesting they were appropriate for the intended level of difficulty and an appropriate pre-course learning activity. Post-course completion resulted in increased scores with both formats. Both delivery methods worked well in all regions and overall quality depends on applying a solid item development and validation process.

Introduction: Surgeons, internal medicine physicians, nurses, and other members of the healthcare team managing older adults with a fracture all have barriers to attending educational courses, including time away from practice and cost. Our planning group decided to create and evaluate a hospital-based educational event to address, meet, and improve the care of older adults with a fracture. Materials and Methods: A committee of surgeons and geriatricians defined 3 learning objectives to improve knowledge and attitudes in co-managed care. They designed a 1-day educational event consisting of a departmental visit, a review of cases, a planning session to identify gaps and plan changes, and presentations on selected topics. Thirteen hospitals worldwide completed an 8-question online application form, and 7 sites were selected for delivery over 3 years in Denmark, Colombia, Thailand, Paraguay, Switzerland, and the Dominican Republic. Results: Each event was conducted by 1 or more visiting surgeons and geriatricians, and the local team leaders. The most common challenges reported in the applications were preoperative assessment or optimization, delayed surgery, lack of protocols, access to a geriatrician, teamwork, and specific aspects of perioperative and postoperative care. In each department, 4 or 5 goals and targets for implementation were agreed. The presentations section was customized and attended by 20 to 50 team members. Discussion: Topics selected by a majority of departments were principles of co-managed care (7), preoperative optimization (7), and management of delirium (4). Follow up was conducted after 3 and 12 months to review the degree of achievement of each planned change and to identify any barriers to complete implementation. Conclusions: Hospital-based events with visiting and local faculty were effective to engage a broader audience that might not attend external courses. A performance improvement component with goal setting and follow up was acceptable to all host departments.

The number of patients undergoing joint replacement and preservation procedures continues to increase worldwide. Globally, there is no standardized educational pathway, training program, or recognized certification program for surgeons in these procedures. Development and implementation of new competency-based curricula to deliver specific educational events and resources may help trainees and practicing surgeons be able to perform these procedures more effectively and therefore improve patient outcomes in their respective countries. Ideally, a curriculum would be globally standardized and professionally designed to interactively meet the needs of surgeons. A competency-based approach with built-in assessment and evaluation processes is today's educational standard.

Study Design: Prospective study. Objectives: To develop, operationally define, and seek consensus from procedure experts on the metrics that best characterize a reference approach to the performance of a minimally invasive unilateral laminotomy for bilateral decompression (ULBD) for lumbar spinal stenosis. Methods: A Metrics Group consisting of 3 experienced spine surgeons (2 neurosurgeons, 1 orthopedic surgeon), each with over 25 years of clinical practice, and an educational expert formed the Metrics Group that characterized a lumbar decompression surgery for spinal stenosis as a “reference” procedure. In a modified Delphi panel, 26 spine surgeons from 14 countries critiqued these metrics and their operational definitions before reaching consensus. Results: Performance metrics consisting of 6 phases with 42 steps, 21 errors, and 17 sentinel errors were identified that characterize the procedure. During the peer review, these were evaluated, modified, and agreed. Conclusions: Surgical procedures can be broken down into elemental tasks necessary for the safe and effective completion of a reference approach to a specified surgical procedure. Spinal experts from 16 countries reached consensus on performance metrics for the procedure. This metric-based characterization can be used in a training curriculum and also for assessment of training and performance in clinical practice.

Webinars have been used in medical education since 2006 and are now part of the educational offerings of many organizations, including universities, societies, and industry for healthcare trainees and professionals. They are frequently used for continuing medical education (CME) and continuing professional development (CPD) for internal medicine physicians, pharmacists, nurses, and surgeons. There is very limited evidence for the positive impact of these educational events on patient care, however, there is literature that suggests they have educational value for various audiences. Based on our own extensive experience, evaluation data, and key findings over the past decade and a review of the literature, this guide proposes best practices for planning, developing, delivering and evaluating webinars as a part of your curriculum. We propose six phases with steps and questions to help achieve the key purposes of each phase.

OBJECTIVETraumatic brain injuries (TBIs) are a significant disease burden worldwide. It is imperative to improve neurosurgeons' training during and after their medical residency with appropriate neurotrauma competencies. Unfortunately, the development of these competencies during neurosurgeons' careers and in daily practice is very heterogeneous. This article aimed to describe the development and evaluation of a competency-based international course curriculum designed to address a broad spectrum of needs for taking care of patients with neurotrauma with basic and advanced interventions in different scenarios around the world.METHODSA committee of 5 academic neurosurgeons was involved in the task of building this course curriculum. The process started with the identification of the problems to be addressed and the subsequent performance needed. After this, competencies were defined. In the final phase, educational activities were designed to achieve the intended learning outcomes. In the end, the entire process resulted in competency and outcomes-based education strategy, including a definition of all learning activities and learning outcomes (curriculum), that can be integrated with a faculty development process, including training. Further development was completed by 4 additional academic neurosurgeons supported by a curriculum developer specialist and a project manager. After the development of the course curriculum, template programs were developed with core and optional content defined for implementation and evaluation.RESULTSThe content of the course curriculum is divided into essentials and advanced concepts and interventions in neurotrauma care. A mixed sample of 1583 neurosurgeons and neurosurgery residents attending 36 continuing medical education activities in 30 different cities around the world evaluated the course. The average satisfaction was 97%. The average usefulness score was 4.2, according to the Likert scale.CONCLUSIONSAn international competency-based course curriculum is an option for creating a well-accepted neurotrauma educational process designed to address a broad spectrum of needs that a neurotrauma practitioner faces during the basic and advanced care of patients in different regions of the world. This process may also be applied to other areas of the neurosurgical knowledge spectrum. Moreover, this process allows worldwide standardization of knowledge requirements and competencies, such that training may be better benchmarked between countries regardless of their income level.

IntroductionFormal training for surgeons regarding intraoperative imaging is lacking. This project investigated the effect of an educational intervention focusing on obtaining and assessing a standardized lateral view of the proximal femur during intramedullary nailing of a pertrochanteric fracture.Materials and methodsAnatomical landmarks of the proximal femur that can be identified using intraoperative fluoroscopy and criteria for image quality, i.e. quality of projection were defined in a consensus process, followed by the development of educational materials and a 7-item checklist. Five surgeons from 5 Trauma Centers in 4 countries participated. Each surgeon a) assessed 5 of their own retrospective cases and 5 retrospective cases from 4 colleagues from their clinic, b) viewed an educational video and poster and re-assessed the same cases, and c) assessed the intraoperative images of 5 prospectively collected consecutive cases of their own and of colleagues afterwards.ResultsThe percentage of positive ratings for image quality increased from 72% prior to educational intervention to 88% after intervention (p < 0.001), and number of “not assessable” images decreased significantly. Percentage agreement between surgeons on the assessments increased from 75% to 87%. The proportion of best possible ratings for fracture reduction and implant position increased from 58% to 72% and from 49% to 66%, respectively. Percentage agreement between surgeons on assessment of reduction and implant position increased.Discussion and conclusionsA focused educational intervention can improve surgeons’ ability to obtain and assess lateral view intraoperative images of the proximal femur and can improve the quality of reduction and implant positioning.

OBJECTIVE: Performance improvement (PI) programs are an educational tool used to analyze clinical performance of clinicians. The effect of this tool has not been fully explored in orthopedic and trauma surgery.DESIGN AND SETTING: A needs assessment was conducted in connection with a worldwide webinar on magnetic resonance imaging in spinal injuries to identify the clinical need for an educational intervention. A 3-step PI process was defined and implemented over a 6-month period in 1 hospital department. Opportunities for improvement were identified by applying a 10-item quality checklist to 26 cases. A focused educational intervention was delivered to address the identified gaps, and a set of 22 posteducation cases was compared.PARTICIPANTS: The department of radiology and the department of trauma surgery of a level I university hospital participated in this study.RESULTS: A total of 26 cases collected before the educational intervention showed several areas for potential improvement. Important information was not provided by the surgeons in their communication with the radiologist. The educational intervention outlined the data and suggested actions. Comparing the information transfer of the preintervention and postintervention data, there was a significant improvement following the intervention (p = 0.0013). CCONCLUSION: Our PI program was able to demonstrate a significant influence on the behavior and the attitude of surgeons and radiologists. (C) 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Introduction Neutral sagittal balance is key for painless upright posture and a large offset of sagittal balance may cause low back pain and correlates with impaired quality of life. Lumbar sagittal balance can easily be assessed on a standing X-ray, however, it is still a new concept to many spine specialists and radiologists. Materials and Methods A performance improvement program was developed to enable radiologists and neurosurgeons to quickly assess lumbar sagittal balance. Baseline knowledge and reporting were analyzed. Clinical tools to measure lumbar sagittal balance were taught with a 30-minute presentation. Following this, a spine surgeon helped colleagues measure their first patients. Results At baseline, 42% of 75 patients showed problems with lumbar sagittal balance but basic knowledge of sagittal balance was low: only 10% of pre- and post-treatment X-ray reports and only 1% of neurosurgical reports included information on sagittal balance. The 30-minute presentation empowered the target audience with the clinical skills to measure, interpret, and report lumbar sagittal balance on a standing X-ray. Intermittent encouragement and support from a spine surgeon helped colleagues to evaluate lumbar sagittal balance in their patients. In the first three months following the presentation, the neurosurgeons documented pelvic parameters in 48% of patients (14 of 29) and the radiologists reported the pelvic parameters on all new lumbar X-rays. Assessing and reporting sagittal balance has become a routine procedure beyond the study period and has led to more profound understanding of deformity induced pain and disability, not only by doctors, but also by patients to whom the origin of their back pain can be explained. Conclusions A short teaching presentation on a poorly known yet important clinical concept enables radiologists and spine specialists to easily measure and interpret heretofore underused information from the standing lumbar X-ray. Performance improvement programs are a valuable educational intervention for surgeons and to engage teams in interdisciplinary learning.

Introduction Performance improvement (PI) programs are an educational tool to analyze clinical parameters taking the behavior and attitude of clinicians into account.1 The impact of this tool is not fully explored in orthopedic and trauma surgery. This educational research aimed to deliver an effective PI program to orthopedic trauma surgeons, neurosurgeons, and radiologists to improve communication and the use of MRI in spinal trauma. Materials and Methods Following a worldwide web session on MRI in spinal injuries to identify the clinical need for an educational intervention, a three-step PI process was defined and implemented over a 6-month period in a hospital department. Opportunities for improvement were identified by applying a 10-item quality checklist to 26 cases. Then a focused educational intervention was delivered to address identified gaps, and a set of 22 post-education cases was compared. Results A total of 26 cases collected before the educational intervention showed several areas for potential improvement. In only 5 of the 26 cases, a specific trauma mechanism or a possible inflammatory or malignant illness was mentioned by the surgeon, where such information may lead to a change in MRI sequence planning. In 23 cases, the radiologist did not believe that the communication led to a change of plan, although sequences other than usual were performed. The educational intervention outlined the data and suggested actions. Comparing the information transfer of the pre- and postinterventional data there was a significant improvement following the intervention ( p = 0.0013). Following the intervention, the communication between surgeons and radiologists significantly influenced the sequences ( p = 0.0152). Conclusion There are specific aspects that may be improved concerning communication between the surgeon and the radiologist. Our PI program was able to demonstrate a significant influence on the behavior and attitude of surgeons and radiologists. In the future, the impact on patient-related outcome parameters has to demonstrate the clinical influence of PI programs in the care of spine patients. References Martin C, Rüetschi U, Cunningham M. Design and implementation of performance improvement programs for orthopedic trauma surgeons. Presented at: AMEE Conference; 2013

Research by AOTrauma's orthogeriatrics education taskforce identified ongoing educational needs for surgeons and trainees worldwide regarding the medical management of older adults with a fracture. To address practicing surgeons' preference for increased use of mobile learning, a point-of-care educational app was planned by a committee of experienced faculty. The goals were to deliver the app to surgeons, trainees, and other healthcare professionals, to measure usage, and to evaluate the impact on patient care.The committee of geriatricians and surgeons designed and developed four modules on osteoporosis, delirium, anticoagulation, and pain based on published evidence and the content was programmed into mobile app formats. A registration form was integrated and a 14-question online evaluation survey was administered to users.The AOTrauma Orthogeriatrics app was installed by 17,839 users worldwide between September 2014 and October 2015: Android smartphones (44 %), iPhones (32 %), iPads (15 %), Android tablets (9 %). 920 users registered and 100 completed the online evaluation: orthopedic/trauma surgeons (67 %), residents/fellows (20 %), and other professionals (13 %). Ratings for all aspects were 4 or higher on a 1-5 Likert scale (5 = Excellent). 80 % of evaluation respondents found the answer to their question or educational need on their last visit, and 26 of 55 respondents (47 %) reported making a change in an aspect of their management of patients as a result of their learning from the app.The orthogeriatrics app reached its intended audiences and was rated highly as a method of providing education to help improve patient care. Content input by experienced faculty and app improvements based on user feedback were key contributors to successful implementation.

INTRODUCTION:Measuring the outcomes of educational activities at the performance level is a challenge for all medical educators. This study reports retrospective outcomes data from the administration of a commitment to change (CTC) at orthogeriatrics courses and how the findings were used for curriculum improvement.METHODS:During 2010-2012, a CTC questionnaire was administered at 8 educational courses attended by 513 orthopedic and trauma surgeons and medicine physicians in 5 countries. The CTC asked if physicians intended to change anything in their clinical practice as a result of participating and to list their specific changes. A 3-month follow-up was conducted to assess the status of intended changes and identify barriers to implementation.RESULTS:Two hundred seventy-six (54%) of the 513 course participants and faculty reported at least 1 intended change in their clinical practice (485 specific changes overall). The intended changes were quantified and analyzed further based on 10 competencies for orthogeriatrics. Follow-up responses were received for N = 150 (31%) of the intended changes. Of these changes, 24% were fully implemented, 51% were partially implemented, and 25% were not implemented. The main barriers to implementation were categorized as "ongoing process (needs more time)" and "requires more discussion, collaboration, or support."DISCUSSION:CTC is an effective tool for self-reported measurement of outcomes of educational activities at the performance level with orthopedic surgeons and an interprofessional audience. Analysis based on a framework of competencies enables curriculum improvement by identifying content that could be adjusted and new materials to address the issues and barriers that were reported.

Background: Surgical education is continually expanding to encompass new techniques and technologies. It is vital that educational activity is directed at gaps in knowledge and ability to improve the quality of learning. Aim: The aim of this study is to describe a published learning assessment toolkit when applied to participants attending AOTrauma Orthogeriatric Fracture courses. Methods: Precourse, participants received a questionnaire covering 10 competencies to assess knowledge gaps and a 20-question clinical knowledge test. The knowledge gap between perceived and desired knowledge was correlated with clinical knowledge test results to help course faculty focus the course curriculum to meet identified educational needs. A commitment to change survey was also administered. Results: Over 3 courses, 48% of registered attendees responded to the precourse survey, 44.5% responded postcourse. The precourse gap scores were generally highest for 2 competencies (“address secondary prevention,” “build a system of care”) indicating a higher level of motivation to learn in these topics and lowest for a variety of competencies (eg. “restore function early,” “co-manage patient care in the US surgeons group”) indicating lower motivation to learn in these competencies. These precourse gap scores guided adaptations in the course structure. Postcourse gaps were reduced in the 4 cohorts. Large improvements were seen in “Address secondary prevention” and “Build a system of care” in many of the cohorts. Competencies with the lowest precourse knowledge test scores were noted in each cohort. Where low pretest scores were noted, it highlighted the need for faculty to put appropriate emphasis on these topics in the delivery of the course content. Conclusion: The technique of evaluating and identifying gaps in knowledge and ability allows course designers to focus on areas of deficits. Measurable success was shown with a subjectively decreased gap score and objectively improved clinical knowledge, as demonstrated by improved test results after course completion.

The corrosion resistance of 33 different conversion coatings applied to five different aluminum alloys was tested by salt spray exposure and electrochemical impedance spectroscopy (EIS). Results derived from the two tests were evaluated to determine if a relationship existed. Individual salt spray test panels, with an area of 30 in.2, were visually inspected at regular intervals up to 168 hours of exposure. At each inspection interval, panels were assigned a pass rank if less than 5 pits were observed, or fail rank if more than 5 pits were observed. EIS data were analyzed using a simple equivalent circuit which yielded a “coating resistance”, Rc, which was used as a figure of merit to assess coating performance. Examination of the data showed that both tests could be sensitive discriminators of corrosion protection, but that EIS was more discriminating in the extremes of coating performance. Analysis showed that the probability of achieving a passing salt spray result increased as Rc increased. In the regimes where both tests were sensitive, regression analysis showed that linear relationships could be constructed between the log of Rc and the probability of a coating meeting the pass/fail criterion in salt spray. Based on these relationships, threshold Rc values have been proposed to define the minimum value for which a given coating can be expected to attain a passing result in a 168 hour salt spray test. These values ranged from 2 to 5 x 106 ohm•cm2 for 356, 2024-T3 and 7075-T6,1.5 x 107 ohm•cm2 for 7075-T6, and 2.3 x 107 ohm•cm2 for 3003.