Optimizing Simulation-Based Training in Orthopedics: Exploring Deliberate Flawed Performance for Dynamic Hip Screw Osteosynthesis

Proximal femoral fractures (PFF) are associated with increased mortality when surgical intervention is delayed, with evidence supporting osteosynthesis within 12 to 24 hours of admission to minimize risk.1, 2 Consequently, surgical procedures for PFF should be mastered by orthopedic trainees early in their career. In Denmark, this necessity is reflected in the first-year specialist training curriculum, which designates PFF surgery as one of three procedures requiring mandatory competence assessment.3 From 2013 to 2019, orthopedic trainees performed 66% of all registered PFF surgeries in Denmark.4 However, evidence suggests that surgeries performed by surgeons in training can be associated with higher reoperation rates.2,5,6 Simulation-based training (SBT) has been proposed to reduce this risk, as it is associated with superior learning outcomes compared to other instructional modalities.7 In a Danish national needs assessment of SBT, osteosynthesis for PFF was ranked 2nd of 33 prioritized procedures within orthopedic surgery.8 Simulators for SBT of PFF osteosynthesis are available. One of them is the Swemac TraumaVision simulator and several studies have supplied both supporting validity evidence for the imbedded tests and evidence supported mastery standards for trainees to achieve before continued practice on patients in the operating room under supervision of senior colleagues.9-11 Accordingly, SBT is now part of the Danish national curriculum for specialist training in orthopaedic surgery.12 The training is based on directed self-regulated learning (DSRL), where trainees receive feedback after each iteration of training and use it to improve their performance in subsequent iterations. While DSRL appears to be noninferior to instructor-regulated training,13 experimental studies suggest a potential downside. Feedback given during training may improve immediate performance but can adversely affect long-term retention and the transfer of skills to new settings.14,