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A Comparison of Orthopaedic Resident Performance on Surgical Fixation of an Ulnar Fracture Using Virtual Reality and Synthetic Models
Justin LeBlanc, MD, MSc1; Carol Hutchison, MD, FRCS(C)1; Yaoping Hu, PEng2; Tyrone Donnon, PhD3
1 Department of Surgery, Health Science Centre, Room Orthopaedic Surgery G207, University of Calgary, 3330 Hospital Drive N.W., Calgary, AB T2N 4N1, Canada. E-mail address for J. LeBlanc: leblanc.justin@me.com
2 Department of Electrical and Computer Engineering, Schulich School of Engineering, University of Calgary, 2500 University Drive N.W., Calgary, AB T2N 1N4, Canada
3 Department of Community Health Sciences, University of Calgary, 3330 Hospital Drive N.W., Calgary, AB T2N 4N1, Canada
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Investigation performed at the Departments of Surgery, Electrical and Computer Engineering, and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada

Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 May 01;95(9):e60 1-6. doi: 10.2106/JBJS.K.01284
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Surgical trainees develop surgical skills using various techniques, with simulators providing a safe learning environment. Fracture fixation is the most common procedure in orthopaedic surgery, and residents may benefit from simulated fracture fixation. The performance of residents on a virtual simulator that allows them to practice the surgical fixation of fractures by providing a sense of touch (haptics) has not yet been compared with their performance using other methods of practicing fracture fixation, such as a Sawbones simulator model. The purpose of this study was to assess whether residents performed similarly on a newly developed virtual simulator compared with a Sawbones simulator fracture fixation model.


A stratified, randomized controlled study involving twenty-two orthopaedic surgery residents was performed. The residents were randomized to first perform surgical fixation of the ulna on either the virtual or the Sawbones simulator, after which they performed the same procedure on the other simulator. Their performance was evaluated by examiners experienced in fracture fixation who completed a task-specific checklist, global rating scale (GRS) form, and time-to-completion record for each participant on each simulator.


Both simulators distinguished between differing experience levels, demonstrating construct validity; for the Sawbones simulator, the Cohen d value (effect size) was >0.90, and for the virtual simulator, d was >1.10 (p < 0.05 for both). The participants achieved significantly better scores on the virtual simulator compared with the Sawbones simulator (p < 0.05) for all measures except time to completion. The GRS scores showed a high level of internal consistency (Cronbach α, >0.80). However, Pearson product-moment correlation analysis showed no significant correlations between the results on the two simulators; therefore, concurrent validity was not achieved.


The newly developed virtual ulnar surgical fixation simulator, which incorporates haptics, shows promise for helping surgical trainees learn and practice basic skills, but it did not attain the same standards as the current standard Sawbones simulator. The procedural measures used to assess resident performance demonstrated good reliability and validity, and both the Sawbones and the virtual simulator showed evidence of construct validity.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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