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Lifelike fracture simulation: An innovative paradigm in trauma education

Diligent maintenance of technical, procedural and interpersonal competencies is essential for the training of Orthopaedic and Trauma Surgeons. The DGU recommends a series of courses which provides the framework for this maintenance, a framework which now boasts a versatile new component: Lifelike Fracture Simulation. DGU: Germany Society of Trauma Surgery Whitebook: The Whitebook is intended for Doctors and Surgeons and summarizes the challenges of trauma treatment as well as providing advice to overcome those challenges. Published in 2016, its objective is to allow any patient suffering from severe trauma in Germany to be treated at any time, at any place, and with the same high quality of treatment. It aims to increase a patient´s chance of survival and maximize quality of life post-recovery.

A New Paradigm in the Whitebook For ten years the DGU has published regular “recommendations regarding structure, equipment, organisation and quality in the care of severely injured patients” to improve and ensure sustainability of high-quality patient-centred care. The current issue of the Whitebook now recommends that technical, procedural and interpersonal competencies should share equal weight in the construction of training programs in order to maximise quality of care for severely injured patients. Experts have determined that, in 70% of errors during medical treatment, the primary cause is a deficiency in cognitive and interpersonal skills. Good teamwork, effective communication, structured and evidence-based decision making, as well as a professional and measured approach to stress management are all cornerstones of successful treatment. The capabilities these cornerstones represent inform the fundamental principles of a new standardized course concept: “Lifelike Fracture Simulation”. This concept is organized in cooperation with BIKMED, a subsidiary of AUC (Akademie der Unfallchirurgie GmbH), and the Trauma Academy (TA) GmbH. This standardized course concept and its principles will also see use in courses run by University partners. Participants are provided a well-structured handbook that gives clear guidance and orientation for the course, this will guide them through a series of sessions with the aim of improving the quality of their patient care. The participants of “Lifelike Fracture Simulation” courses are trained with the support of a team of renowned instructors and experts who are in turn supported by the very latest technologies. An important objective of the course is to foster a personable atmosphere in which individual and openminded exchange of ideas is encouraged.

Firstly, the participants will undertake treatment planning in small teams. Different treatment approaches will be shared, reviewed and evaluated in subject-specific discussions, all with continuous support from instructors who are experts in their respective fields. This session is supported by imaging (e.g. X-Rays or CT scans) and 3D-printed models of the fracture. Participants then move to the wet lab to take part in the hands-on surgical portion of the course. Here participants are given the opportunity to test their chosen treatment approaches by performing surgery on pre-fractured human specimens. This surgical session is supported by high quality, on demand 3D X-ray imaging as well as continued support by the team of instructors. At the conclusion of the surgical session the participants will debrief and review their methods. During these sessions there exists a real opportunity to share knowledge across a wide range of medical philosophies and institutions.

“Lifelike Fracture Simulation” Combines the Newest Technologies with Innovative Didactics Trauma Academy and BIKMED have worked in close cooperation to develop this course concept, but what exactly is “Lifelike Fracture Simulation”? “Lifelike Fracture Simulation” allows each course participant to independently perform surgery on a pre-fractured human specimen with intact soft tissue. Vigilant quality control protocols with a strong focus on ethical principles require all specimens to be procured from approved human soft tissue banks, these specimens are then fractured according to common fracture classifications. To this end several machines, that utilise biomechanical algorithms, have been specifically designed to generate the equivalent fractures. Specific fracture causes, such as falling of a bike, are simulated by these machines and thanks to frequent input from experts in trauma surgery the accuracy and validity of these simulations are constantly improved. With repeatable accurate fractures on specimens, courses can be structured around standardised, lifelike fractured specimens. Participants can train their treatment approaches and decision-making processes from planning, to surgery, all the way up to the final post-surgery X-ray during a single course – a global first that demonstrates the uniqueness of this course concept.

“Lifelike Fracture Simulation” Reflects the Daily Challenges of a Surgeon Courses using “Lifelike Fracture Simulation” employ the acronym “OK,DOC” to describe the five key competencies which make up the course´s fundamental structure A typical course takes place over two days. Participants will each perform surgery on pre-fractured specimens in order to prepare them for their clinical routine. The hands-on surgical portion of the course will take the lion’s share of course time. Every course starts with “Organise your plan”. During this theory-based session experts will share their knowledge and experience, at first in by lecture and then in open forum. The next session, “Know your Implant” is a unique feature of “Lifelike Fracture Specimen” courses. This session takes on a “speed-dating” format in which med-tech industry partners introduce their osteosynthesis implant systems. There are always at least three competing med-tech industry partners present to introduce their products. The “speed-dating” rotating format allows participants to become familiar with a greater diversity of osteosynthesis implants as well helping to eliminate the inherent bias of single-sponsor course formats. “Define your plan” focuses on strategy. In this session small teams of participants will choose the most appropriate implant system for their case and decide the best surgical approach for their upcoming procedure. This planning is supported by the very latest in diagnostic technology. Participants have access to patient data (patient data is anonymised), X-rays, CT-scans, VR Segmentation as well as a 3D print model of their fracture. Each team then presents their planning before continuing on to the surgical session which takes place in the wet lab where they can “Operate your plan” (surgical session time 2-3 hours at CADLAB COLOGNE). In the final session of the course, “Challenge your plan”, results of the surgical session are presented and analysed by the entire group using the latest intra- and postoperative 3D-imaging technology.

Trauma Academy course structure Due to the personable and cooperative atmosphere of the course, this final session is a vivid and open discussion focusing on the challenges faced by participants and a sharing of lessons learned. This, often enthusiastic, part of the course is followed by a group dinner at a local restaurant. The next day, the participants will return to face a more complicated fracture. This allows them to put into practice the newly gained knowledge, experiences and camaraderie developed over the previous day. Participants will also leave with an official certification (CME) as well as a certification from the Trauma Academy itself. A Story of Success, Starting in 2018 This course concept was piloted successfully for the first time at the end of 2018 in cooperation with BG-Hospitals. Since then, 252 orthopaedic and trauma surgeons have been trained in 14 courses. Many participants have attended numerous different courses for various anatomical regions to broaden and deepen their surgical knowledge. The BG-Hospital´s medical advisory committee support this concept and have since integrated “Lifelike Fracture Simulation” into their internal training programs. The DGU has also expressed support for this concept, and in cooperation with AUC/BIKMED and Trauma Academy will include “Lifelike Fracture Simulation” as an integral part of their course structures by the end of March 2020. A Planned Substitute for Real Surgical Experience Surgical training in its present form is becoming a more daunting prospect in the face of drastically greater bureaucratic regulation and non-patient activities. The need to restructure the current training system and find new alternatives is self-evident. The rapid acceptance of this course concept into the DGU Whitebook represents a confirmation of its value to surgical education. The high demand for practical and realistic training indicates the necessity of this hands-on, open forum training methodology. However, the extent to which this “Lifelike Fracture Simulation” can replace or reduce the number of cases to be performed by residents or young surgeons must still be discussed. Courses run by BIKMED and Trauma Academy can be booked at In Germany, several universities in Düsseldorf, Kiel, Aachen, and Cologne are also organizing hands-on courses which can also be booked at the above website. You can also find an updated course calendar at Authors: PD Dr. Matthias Münzberg BG Kliniken Ludwigshafen, Head Interdisciplinary Rescue and Emergency Medicine Center Markus Blätzinger Munich, General Manager AUC Judith Pfeiffer Cologne, General Manager Trauma Academy TA GmbH This article was published in German in the OUMN Magazine in April 2020.

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