The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 90, Issue 12

Ethics in Practice | December 01, 2008

Ethical Dilemmas in Orthopaedic Surgical Training

Graeme Holt, MBChB, MRCS¹; Tom Nunn, MBChB, MRCS¹; Alberto Gregori, MBChB, FRCS(Tr&Orth)¹

¹ Department of Orthopaedic and Trauma Surgery, Hairmyres Hospital, Eaglesham Road, East Kilbride G75 8RG, United Kingdom. E-mail address for G. Holt: graemeholt@btinternet.com

View Disclosures and Other Information

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. A commercial entity (B. Braun Aesculap, United Kingdom) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors, or a member of his or her immediate family, is affiliated or associated.

The Journal of Bone and Joint Surgery, Inc.

J Bone Joint Surg Am, 2008 Dec 01;90(12):2798-2803. doi: 10.2106/JBJS.H.00910

5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Article

Comments (0)

text A A A

Extract

The involvement of surgical trainees in surgical procedures forms an integral part of traditional orthopaedic surgical education. While the need to train surgeons is unquestioned, a patient may not necessarily benefit from receiving treatment from an inexperienced surgeon and, indeed, may suffer a poorer outcome as a consequence^1-7. As such, the process of orthopaedic surgical training is one that highlights a number of important ethical issues. While the ethical implications of clinical research have been the subject of extensive discussion and guideline development, the ethics of surgical training has received comparatively little attention^8-10. Both clinical research and surgical training are analogous in that each involves participation in a process that, while potentially benefiting society as a whole, may result in harm to the individual. In this paper, we discuss the ethical issues that are salient to orthopaedic surgical training and examine how recent technological innovations may offer a potential solution to such issues.

Figures in this Article

Introduction

What Do We Mean by "Ethics?"

While medical ethics is a complex topic, it is fundamentally a code of professional conduct, commonly based on the four principles described by Beauchamp and Childress¹¹. These principles are nonmaleficence, beneficence, autonomy, and justice.

Nonmaleficence means that doctors have a basic obligation not to inflict harm on their patients, either intentionally or carelessly. Harm in terms of bioethics refers to physical harm such as pain, disability, or death. Unfortunately, all surgical interventions inevitably cause some harm and unavoidable risk, so this principle is impossible to guarantee.

Beneficence refers to the principle of intervening to benefit the well-being of an individual. As surgeons, this basic principle is what we try to achieve in every procedure we undertake. Beauchamp and Childress highlight the differences between the principles of nonmaleficence and beneficence. The duty to "do no harm" invariably prohibits actions, while the duty to help generally prescribes intervention¹¹.

Autonomy is described by Beauchamp and Childress as "personal rule of the self, free from both controlling interferences by others and from personal limitations that prevent meaningful choice."¹¹ Autonomy requires that an individual is independent from controlling influences and has the capacity for intentional action. The most common way in which a surgeon demonstrates respect for a patient's autonomy is by obtaining informed consent for a surgical procedure. As it is impossible to guarantee beneficence or nonmaleficence for any surgical procedure, informed consent allows an individual to balance the potential benefits of surgery against the associated risks. Such informed consent also extends to informing a patient that a surgical trainee may have some role during the surgical procedure. Although patients are able to exert autonomy prior to an elective surgical procedure in their decision to undergo that procedure, they are unable to do so during the procedure. In such circumstances, the principles of beneficence and nonmaleficence are of particular importance because the patient is completely dependent on the decisions and operative skills of the surgical team while he or she is under the effects of anesthesia.

Justice may relate to several issues, including distributive justice (distribution of health-care resources), rights-based justice (patient rights), and legal justice (upholding the law). Distributive justice refers to fair, equitable, and appropriate distribution of health-care resources. It is widely recognized that health-care resources are finite and that difficult choices must be made regarding the distribution of such resources. This applies both to material resources and to medical staffing. Within any orthopaedic department, each individual surgeon will be unique with regard to surgical experience and surgical skills. It is therefore inevitable that individual patients will receive varying types of care depending, to some extent, on who performs the procedure¹².

Conflicts of Interest—The Surgeon-Patient-Trainee Relationship

Surgical training in Europe and North America has traditionally been based on the apprenticeship model. This model involves a complex relationship between the surgical trainer, the patient, and the trainee. The primary role of any surgeon is that of health-care provider. With this role comes an obligation of "duty of care" to provide each patient with the highest level of care within the available resources¹². The educational role of the surgical trainer is to impart knowledge and operative skills while providing a supervised and protected environment to protect trainees from situations in which they may take serious risks and compromise the standard of patient care. However, in maintaining this teaching commitment, the potential to compromise the duty of care to their patient remains ever present, just as allowing inexperienced surgeons to operate inevitably introduces an element of added risk to the patient^3-6. No matter how closely one may supervise a trainee, the potential for inadvertent damage to surrounding anatomical structures or incorrect positioning of a surgical implant cannot be eliminated. If a patient undergoes suboptimal surgery as a result of the inexperience of a surgical trainee, then the trainer has failed in his or her duty of care to the patient. It should also be noted that the index surgical procedure forms only one part of the trainee surgeon's total experience in the management of a patient; surgical training also involves the development of skills in the preoperative evaluation and assessment and postoperative management of patients as well as the development of numerous other skills. The principles discussed in this paper relate mainly to training in the operating room; however, they also apply to the many practical procedures (such as central venous catheterization) that are common to both surgical and medical training.

Despite concerns of potentially compromised outcomes when surgery is undertaken by trainees, evidence from the surgical literature is often contradictory. A number of studies that examined outcomes after abdominal surgery and after hepatic and colonic resections have reported less favorable outcomes after procedures performed by less-experienced surgeons^4,5,13; however, other such studies have reported no difference in outcome^14-17. Robson et al. reported that inguinal hernia repair was associated with a higher recurrence rate when the procedure was performed by an unsupervised junior surgical trainee rather than a senior trainee or a consultant surgeon; however, no difference was found when the junior surgical trainee was supervised¹⁸. Higher revision rates after lower-limb amputation for peripheral vascular insufficiency have also been reported in association with the procedure being performed by a junior surgeon^19,20.

While the relationship between operative volume and outcome has been widely reported³, there is limited evidence in the orthopaedic literature regarding the effect of surgeon grade on surgical outcome^21,22. Moran et al. found no significant difference in the short-term clinical outcome of total hip arthroplasty performed by supervised trainees compared with consultant orthopaedic surgeons²¹. Acetabular anteversion was significantly less prevalent in trainee-performed procedures (p < 0.05); however, this was not associated with an increased dislocation rate. Woolson and Kang evaluated the early clinical results and complications associated with primary total hip and knee arthroplasty at a hospital that had both university teaching and private practice orthopaedic services²². Teaching and active participation from residents and fellows during total hip and total knee arthroplasty were associated with a longer operative time; however, this did not have a detrimental effect on the early clinical results. In summary, unsupervised junior trainees would appear to have poorer outcomes, particularly in association with more complex procedures. However, the surgery performed by senior and appropriately supervised junior trainees is associated with outcomes similar to those of consultant surgeons.

The Kantian Ideal

By nature, orthopaedic residents are a motivated group who are keen to undertake as many operations as possible to achieve comprehensive orthopaedic surgical training. This enthusiasm is often expressed most ardently when complex or rare cases arise. A number of orthopaedic injuries and disorders can be treated either operatively or nonoperatively. This can lead to a situation in which the surgeon may wish to perform a procedure more for the surgical experience than for a clinical indication. A similar conflict may arise when a surgeon wishes to perform a procedure for monetary reasons. Such situations pose an important ethical dilemma that is addressed by a principle known as the "Kantian Ideal."²³

Immanuel Kant has been quoted: "Act so that you use humanity, as much in your own person as in the person of every other, always at the same time as end and never merely as means."²³ Upholding this ideal entails that one should always treat each individual as being intrinsically valuable in his or her own right, and, conversely, that one should never use another person merely as a means toward attaining a goal. In their paper, Le Morvan and Stock eloquently explore the conflict between the Kantian ideal and the reality of medical practice²⁴. This conflict arises from the fact that surgical skills must be learned. To become a surgeon, one must acquire manual skills as well as factual knowledge. The development of physical abilities as well as the ability to make correct judgments requires physical practice—learning from books alone is not sufficient. The process of developing the complex motor skills required for surgery is greatly different than the process of learning pure cognitive skills. In medical specialties (and in the postoperative management of surgical patients), senior physicians are able to give advice and supervise the decision-making process of trainees and can directly intervene to reduce the risk of harm to a patient. This differs greatly from the practice of surgery, during which a trainee has direct manual control of the procedure and is capable of making an error (such as dividing a nerve) before the supervising surgeon may be able to manually intervene. The independent and competent performance of a surgical procedure involves the use of cognitive, perceptual, and motor skills. Fitts and Posner suggested that the development of complex motor skills is sequential and that we progress through specific phases as we learn^25,26. Phase I (the cognitive phase) involves the development of the component parts of the skill. In this stage, many mistakes are made as the individual learns new movements and techniques. Phase II (the associative phase) involves linking the component parts into a smooth action and practicing with feedback to perfect the skill. Phase III (the autonomous phase) involves developing the learned skill so that it becomes almost automatic, with little conscious thought while performing the skill. The structure of medical education reflects this observation. One typically progresses from coursework, to observing and assisting, and then to supervised residency before attaining full professional status. The process of developing and acquiring surgical expertise therefore inevitably requires "practicing" on patients, with one's performance improving along a learning curve^26-30. Learning curves occur in any process in which performance improves as a function of practice, and they are particularly relevant to the performance of complex surgical procedures. Thus, patients treated at the beginning of a surgeon's learning curve are exposed to higher risk, with future patients benefiting from this exposure^26-30. Treating patients in this way is, on initial examination, a potential violation of Kant's principle.

While it is immediately clear that surgical training potentially exposes patients to increased risk, it is important to note that learning curves are not limited to a small period of time at the beginning of a surgeon's career. Learning curves are ubiquitous—surgery is constantly advancing, requiring even the most experienced surgeons to acquire new skills throughout their career as new technologies and surgical procedures are developed^27-30. The perils of the learning curve are thus inescapable, whether in senior practice or in residency. It is entirely reasonable for a patient to request that a surgeon who is at the high end of his or her learning curve perform the operation. Few people would wish to be the first individual on whom a surgeon performs a particular procedure, even though every surgeon has to perform a procedure for the first time at some stage in his or her career. One may argue that if patients choose to permit only the most experienced surgeon to perform their procedure, they are acting autonomously in their own personal best interest. However, if all patients were to insist on the most experienced surgeon, this would prevent other surgeons from becoming experienced, which would be detrimental to society as a whole.

In order to uphold the Kantian ideal, surgeons must treat patients as ends in themselves, and never only as a means to other ends. As discussed earlier, in situations in which operative and nonoperative treatments are both acceptable, using the desire to gain operative experience as an indication to perform surgery is a good example of treating a patient as a means to an end—that is, as a tool for surgical training. However, the reality of surgical practice means that surgeons can only acquire certain skills by effectively "practicing" on patients. With the current state of technology and the ubiquity of the learning curve, it is impossible for junior surgeons to learn current techniques or for experienced surgeons to develop new techniques without using patients, at least to some small extent, as a means only. As such, the Kantian ideal, while being a plausible ethical ideal, is essentially inconsistent with the reality of surgical training. From the limited evidence available in the surgical literature, it appears that experienced surgical trainees and supervised junior trainees can deliver postoperative outcomes on par with consultant surgeons^14-22. However, if a surgical trainee is to perform all or part of the procedure (supervised or unsupervised), the patient should be made aware of this fact during the consent process. Similarly, if a patient is to undergo a procedure that is new to a particular (experienced) surgeon, that patient must be fully informed of the potential risks that may be associated with the surgeon's relative inexperience in performing that procedure. By doing so the surgeon is able to observe the principles of both autonomy and justice, which may prevent potential litigious action by the patient.

Potential Solutions to Ethical Dilemmas in Orthopaedic Surgical Training

Surgical training has traditionally been based on the apprenticeship model, with the transfer of knowledge and skills occurring in the operating theater. However, recent reductions in the number of hours surgeons are able to work during residency, coupled with pressures for improved operating-room throughput, have actually resulted in less time for surgical trainees to develop their operative skills³¹. The net effects of such changes will mean that surgical trainees are likely to spend a longer amount of time at the bottom of the learning curve. Although this conflict is in some respects inescapable, developments in technology may potentially allow surgical trainees to progress along the learning curve more quickly without the need for operating on live patients.

Cadaver Workshops

Cadaver workshops allow surgical trainees to practice and develop surgical techniques without any risk to a live patient. While not representing live surgery (as a result of preservation techniques and the lack of active bleeding), such workshops are invaluable to the trainee and are commonly and successfully used in training surgeons to perform the more complex and less common surgical procedures³². However, a combination of cost, lack of available cadavers, and legal restrictions means that, currently, cadaver workshops cannot be used to train all surgical trainees.

Computer-Assisted Surgery

Computer-assisted surgery has been introduced to orthopaedic surgery to provide improved and reproducible orientation of the implant during arthroplasty surgery³³. The applications for this technology have expanded to include total and unicompartmental knee arthroplasty, hip arthroplasty, high tibial osteotomy, and anterior cruciate ligament reconstruction^33-37. Although computer-assisted surgery has been validated in terms of improving implant alignment, the novel nature of this technology means that long-term improvements in implant survival have yet to be demonstrated³⁸. However, the use of computer-assisted surgery in these procedures has potential implications with regard to the ethics of surgical training.

Implant alignment is an important determinant of implant survival and function^39-41. One limitation of conventional hip and knee arthroplasty is limited intraoperative feedback regarding implant alignment. The principal source of feedback to the trainee is the postoperative radiograph; however, because this feedback is not available until after the procedure has been completed, it is difficult to correlate the various intraoperative actions and the positioning of the implant. Conventional alignment techniques are limited in that they act only as visual guides; it is not possible to verify the true accuracy of the intended osteotomies in real time. The accuracy of alignment is largely dependent on the skill of the surgeon. Because such skill can only be developed over the course of many procedures, conventional alignment techniques are prone to inaccuracy, particularly with inexperienced surgeons who are at the bottom of the learning curve⁴². Let us consider total knee replacement as an example. There are many sources of inaccuracy when preparing the tibia and femur for total knee replacement; these sources include poor alignment and/or fixation of the cutting jigs, poor control of the saw blade, and inadequate soft-tissue release^43-47. When using a conventional jig, the surgeon has no way of quantifying the accuracy of the osteotomy. One major advantage of computer-assisted technology is that it provides accurate, unbiased, real-time performance feedback to the surgical trainee and thus increases the trainee's awareness of the potential sources of error during this complex procedure. As discussed earlier in this paper, appropriate feedback is essential during the associative phase of learning because it allows the surgeon to effectively link component parts of a surgical procedure into a smooth action.

Computer-assisted technology is also of benefit to the surgical trainer because it enables the trainer to assess the accuracy of each individual osteotomy in real-time and therefore allows identification of errors intraoperatively rather than when the postoperative radiographs are viewed. Computer-assisted knee arthroplasty has been shown to improve not only the alignment of a knee replacement but also the reproducibility of satisfactory alignment^48-53. As implant alignment is a determinant of implant survival, computer-assisted placement helps maintain the duty of care to the patient even though the procedure has been performed by a less experienced surgeon. However, a major caveat to this approach is that the technology must be used correctly. Computer-assisted surgery is essentially an advanced alignment tool and is not a substitute for surgical experience and training. The trainee must be appropriately supervised and trained in the use of this technology because the output is directly dependent on the quality of data acquisition^54-56.

Virtual Surgery

Although airline pilots have used computer simulation to develop their skills for many years, the surgical world has been somewhat slower to apply this type of technology to the development of surgical skills. This has largely been due to the required complexity of the technology for realistic simulation; however, recent advances in computer simulation and virtual-reality technology may offer another potential solution to reduced exposure to theater-based surgical training. Virtual surgery may take a number of forms and may include synthetic models and complex three-dimensional computer simulations. Such systems enable surgical trainees to develop surgical skills outside of the theater environment^57-62. When performing complex surgical procedures, one does not normally learn by repeatedly performing the procedure from start to completion. In discussing the benefits of computer-assisted surgery as a learning tool for total knee replacement, Stulberg described the deliberate practice model of Ericsson^63,64. He drew the useful analogy of a concert pianist who will practice difficult sections of a piece of music rather than simply playing the piece from beginning to end repeatedly. Virtual reality provides the opportunity for detailed feedback and is useful in that trainees can repeatedly practice what they find to be the most difficult part of the operation. Virtual-reality simulators have been shown to improve the performance of surgical trainees in laparoscopic abdominal surgery^57-62. The application of this technology to orthopaedic surgery has been less widespread, in large part due to the required complexity to provide realistic simulations. However, such virtual simulation has been used in the field of arthroscopic surgery in order to allow trainees to develop surgical skills without the risk of injury to patients⁶⁵. Realistic virtual-reality simulators are expensive, however, which limits their widespread application. Further investigation will be required to determine whether such investment is worthwhile. The ultimate goal would be to eventually eliminate "practicing" on patients; however, this goal is unlikely to be fully attainable in the near future. As it becomes more difficult to be able to offer surgical training time in the operating room, it is likely that the use of such surgical simulators may become commonplace in orthopaedic surgical training programs.

Conclusions

Surgical training is fundamental to the continuity and progression of the orthopaedic profession. The task of training junior surgeons is both difficult and rewarding and involves a number of important ethical issues. Patients are exposed to an increased risk of complications when surgery is performed by inexperienced surgeons, particularly when the operation takes place at the beginning of the surgeon's learning curve. Reductions in the duration of the working week mean that surgical trainees will have less exposure to theater-based surgery. Pressure for increased operating-room throughput, an increase in patient expectations, and an increasing complexity of procedures are all likely to exacerbate this problem. While there are no comprehensive solutions, surgical training will have to adapt to meet such challenges. The increased use of cadaver workshops, virtual-reality simulators, and computer-assisted technology can improve feedback to surgical trainees and allow them to progress along the learning curve without risking adverse outcomes in actual patients. The use of such technologies on a more widespread basis will require a change in the traditional training models and is likely to increase the costs of surgical training. Those who are tasked with training the surgeons of the future have responsibilities both to their patients and their trainees; however, the duty of care to the patient must be protected during the training process. While it is not possible to fully eliminate the risk of an adverse outcome when a trainee performs a surgical procedure, it is imperative to ensure that our surgical trainees receive high-quality, thorough training in order to maintain the high quality of surgical care that our patients have come to expect.

References

Hicks LK, Lin Y, Robertson DW, Robinson DL, Woodrow SI. Understanding the clinical dilemmas that shape medical students' ethical development: questionnaire survey and focus group study. BMJ.2001;322:709-10.322709 2001 [PubMed][CrossRef]

Coldicott Y, Pope C, Roberts C. The ethics of intimate examinations-teaching tomorrow's doctors. BMJ.2003;326:97-101.32697 2003 [CrossRef]

Katz JN, Mahomed NN, Baron JA, Barrett JA, Fossel AH, Creel AH, Wright J, Wright EA, Losina E. Association of hospital and surgeon procedure volume with patient-centered outcomes of total knee replacement in a population-based cohort of patients age 65 years and older. Arthritis Rheum.2007;56:568-74.56568 2007 [CrossRef]

McKay A, You I, Bigam D, Lafreniere R, Sutherland F, Ghali W, Dixon E. Impact of surgeon training on outcomes after resective hepatic surgery. Ann Surg Oncol.2008;15:1348-55.151348 2008 [CrossRef]

Prystowsky JB, Bordage G, Feinglass JM. Patient outcomes for segmental colon resection according to surgeon's training, certification, and experience. Surgery.2002;132:663-72.132663 2002 [CrossRef]

King J, Stamper DL, Schaad DC, Leopold SS. Minimally invasive total knee arthroplasty compared with traditional total knee arthroplasty. Assessment of the learning curve and the postoperative recuperative period. J Bone Joint Surg Am.2007;89:1497-503.891497 2007 [CrossRef]

Rich EC, Gifford G, Luxenberg M, Dowd B. The relationship of house staff experience to the cost and quality of inpatient care. JAMA.1990;263:953-7.263953 1990 [CrossRef]

Jagsi R, Lehmann LS. The ethics of medical education. BMJ.2004;329:332-4.329332 2004 [CrossRef]

Wendler DS, Shah S. How can medical training and informed consent be reconciled with volume-outcome data? J Clin Ethics.2006;17:149-57.17149 2006

Chiong W. Justifying patient risks associated with medical education. JAMA.2007;298:1046-8.2981046 2007 [CrossRef]

Beauchamp TL, Childress JF. Principles of biomedical ethics. 4th ed. New York: Oxford University Press; 1994. 1994

Tomlinson T. Caring for risky patients: duty or virtue? J Med Ethics.2008;34:458-62.34458 2008 [CrossRef]

Prystowsky JB. Are young surgeons competent to perform alimentary tract surgery? Arch Surg.2005;140:495-502.140495 2005 [CrossRef]

Paisley AM, Madhavan KK, Paterson-Brown S, Praseedom RK, Garden OJ. Role of the surgical trainee in upper gastrointestinal resectional surgery. Ann R Coll Surg Engl.1999;81:40-5.8140 1999

Renwick AA, Bokey EL, Chapuis PH, Zelas P, Stewart PJ, Rickard MJ, Dent OF. Effect of supervised surgical training on outcomes after resection of colorectal cancer. Br J Surg.2005;92:631-6.92631 2005 [CrossRef]

Goodwin AT, Birdi I, Ramesh TP, Taylor GJ, Nashef SA, Dunning JJ, Large SR. Effect of surgical training on outcome and hospital costs in coronary surgery. Heart.2001;85:454-7.85454 2001 [CrossRef]

Schol FP, Go PM, Gouma DJ, Kootstra G. Laparoscopic cholecystectomy in a surgical training programme. Eur J Surg.1996;162:193-7.162193 1996

Robson AJ, Wallace CG, Sharma AK, Nixon SJ, Paterson-Brown S. Effects of training and supervision on recurrence rate after inguinal hernia repair. Br J Surg.2004;91:774-7.91774 2004 [CrossRef]

Cosgrove CM, Thornberry DJ, Wilkins DC, Ashley S. Surgical experience and supervision may influence the quality of lower limb amputation. Ann R Coll Surg Engl.2002;84:344-7.84344 2002 [CrossRef]

White SA, Thompson MM, Zickerman AM, Broomhead P, Critchley P, Barrie WW, Bell PR. Lower limb amputation and grade of surgeon. Br J Surg.1997;84:509-11.84509 1997 [CrossRef]

Moran M, Yap SL, Walmsley P, Brenkel IJ. Clinical and radiologic outcome of total hip arthroplasty performed by trainee compared with consultant orthopedic surgeons. J Arthroplasty.2004;19:853-7.19853 2004 [CrossRef]

Woolson ST, Kang MN. A comparison of the results of total hip and knee arthroplasty performed on a teaching service or a private practice service. J Bone Joint Surg Am.2007;89:601-7.89601 2007 [CrossRef]

Kant I. Groundwork for the metaphysics of morals. Wood AW, editor. New Haven, CT: Yale University Press; 2002. p 46-7. 2002

Le Morvan P, Stock B. Medical learning curves and the Kantian ideal. J Med Ethics.2005;31:513-8.31513 2005 [CrossRef]

Fitts PM, Posner MI. Human performance. Belmont, CA: Brooks/Cole; 1967. 1967

Kopta JA. The development of motor skills in orthopaedic education. Clin Orthop Relat Res.1971;75:80-5.7580 1971 [CrossRef]

Lubowitz JH, Sahasrabudhe A, Appleby D. Minimally invasive surgery in total knee arthroplasty: the learning curve. Orthopedics.2007;30(8 Suppl):80-2.3080 2007

Kim PR, Beaulé PE, Laflamme GY, Dunbar M. Causes of early failure in a multicenter clinical trial of hip resurfacing. J Arthroplasty.2008;23(6 Suppl 1):44-9.2344 2008

Cobb JP, Kannan V, Brust K, Thevendran G. Navigation reduces the learning curve in resurfacing total hip arthroplasty. Clin Orthop Relat Res.2007;463:90-7.46390 2007

Peters CL, Erickson JA, Hines JL. Early results of the Bernese periacetabular osteotomy: the learning curve at an academic medical center. J Bone Joint Surg Am.2006;88:1920-6.881920 2006 [CrossRef]

Mestres CA, Revuelta JM, Yankah AC. The European Working Time Directive: quo vadis? A well-planned and organized assassination of surgery. Eur J Cardiothorac Surg.2006;30:571-3.30571 2006 [CrossRef]

Noble PC, Johnston JD, Alexander JA, Thompson MT, Usrey MM, Heinrich EM, Landon GC, Mathis KB. Making minimally invasive THR safe: conclusions from biomechanical simulation and analysis. Int Orthop.2007;31 Suppl 1:S25-8.31S25 2007 [CrossRef]

Delp SL, Stulberg SD, Davies B, Picard F, Leitner F. Computer assisted knee replacement. Clin Orthop Relat Res.1998;354:49-56.35449 1998 [CrossRef]

Jenny JY. Navigated unicompartmental knee replacement. Sports Med Arthrosc.2008;16:103-7.16103 2008 [CrossRef]

Wixson RL. Computer-assisted total hip navigation. Instr Course Lect.2008;57:707-20.57707 2008

Maurer F, Wassmer G. High tibial osteotomy: does navigation improve results? Orthopedics.2006;29(10 Suppl):S130-2. Erratum in: Orthopedics. 2007;30:327.29S130 2006

Hart R, Krejzla J, Sváb P, Kocis J, Stipcák V. Outcomes after conventional versus computer-navigated anterior cruciate ligament reconstruction. Arthroscopy.2008;24:569-78.24569 2008 [CrossRef]

Spencer JM, Chauhan SK, Sloan K, Taylor A, Beaver RJ. Computer navigation versus conventional total knee replacement: no difference in functional results at two years. J Bone Joint Surg Br.2007;89:477-80.89477 2007 [CrossRef]

Longstaff LM, Sloan K, Stamp N, Scaddan M, Beaver R. Good alignment after total knee arthroplasty leads to faster rehabilitation and better function. J Arthroplasty. 2008 May 17 [Epub ahead of print]. 2008

Ritter MA, Faris PM, Keating EM, Meding JB. Postoperative alignment of total knee replacement. Its effect on survival. Clin Orthop Relat Res.1994;299:153-6.299153 1994

Bargren JH, Blaha JD, Freeman MA. Alignment in total knee arthroplasty. Correlated biomechanical and clinical observations. Clin Orthop Relat Res.1983;173:178-83.173178 1983

Rees JL, Price AJ, Beard DJ, Dodd CA, Murray DW. Minimally invasive Oxford unicompartmental knee arthroplasty: functional results at 1 year and the effect of surgical inexperience. Knee.2004;11:363-7.11363 2004 [CrossRef]

Toksvig-Larsen S, Ryd L. Surface flatness after bone cutting. A cadaver study of tibial condyles. Acta Orthop Scand.1991;62:15-8.6215 1991 [CrossRef]

Toksvig-Larsen S, Ryd L. Surface characteristics following tibial preparation during total knee arthroplasty. J Arthroplasty.1994;9:63-6.963 1994 [CrossRef]

Toksvig-Larsen S, Kroon PO, Ryd L. Improved bone cutting using a semirotating saw. A cadaver study of the cut surface on tibial condyles. Acta Orthop Scand.1994;65:412-4.65412 1994 [CrossRef]

Macdonald W, Styf J, Carlsson LV, Jacobsson CM. Improved tibial cutting accuracy in knee arthroplasty. Med Eng Phys.2004;26:807-12.26807 2004 [CrossRef]

Otani T, Whiteside LA, White SE. Cutting errors in preparation of femoral components in total knee arthroplasty. J Arthroplasty.1993;8:503-10.8503 1993 [CrossRef]

Berry DJ. Computer-assisted knee arthroplasty is better than a conventional jig-based technique in terms of component alignment. J Bone Joint Surg Am.2004;86:2573.862573 2004

Victor J, Hoste D. Image-based computer-assisted total knee arthroplasty leads to lower variability in coronal alignment. Clin Orthop Relat Res.2004;428:131-9.428131 2004 [CrossRef]

Chauhan SK, Clark GW, Lloyd S, Scott RG, Breidahl W, Sikorski JM. Computer-assisted total knee replacement. A controlled cadaver study using a multi-parameter quantitative CT assessment of alignment (the Perth CT Protocol). J Bone Joint Surg Br.2004;86:818-23.86818 2004 [CrossRef]

Bäthis H, Perlick L, Tingart M, Lüring C, Zurakowski D, Grifka J. Alignment in total knee arthroplasty. A comparison of computer-assisted surgery with the conventional technique. J Bone Joint Surg Br.2004;86:682-7.86682 2004 [CrossRef]

Chauhan SK, Scott RG, Breidahl W, Beaver RJ. Computer-assisted knee arthroplasty versus a conventional jig-based technique. A randomised, prospective trial. J Bone Joint Surg Br.2004;86:372-7.86372 2004 [CrossRef]

Chauhan SK, Scott RG, Breidahl W, Sikorski JM, Beaver RA. A prospective randomised controlled trial of computer assisted versus conventional knee replacement [abstract]. J Bone Joint Surg Br.2004;86 Suppl IV:442-3.86442 2004

Yau WP, Chiu KY, Zuo JL, Tang WM, Ng TP. Computer navigation did not improve alignment in a lower-volume total knee practice. Clin Orthop Relat Res.2008;466:935-45.466935 2008 [CrossRef]

Biant LC, Yeoh K, Walker PM, Bruce WJ, Walsh WR. The accuracy of bone resections made during computer navigated total knee replacement. Do we resect what the computer plans we resect? Knee.2008;15:238-41.15238 2008 [CrossRef]

Catani F, Biasca N, Ensini A, Leardini A, Bianchi L, Digennaro V, Giannini S. Alignment deviation between bone resection and final implant positioning in computer-navigated total knee arthroplasty. J Bone Joint Surg Am.2008;90:765-71.90765 2008 [CrossRef]

Cauraugh JH, Martin M, Martin KK. Modeling surgical expertise for motor skill acquisition. Am J Surg.1999;177:331-6.177331 1999 [CrossRef]

Fried GM, Feldman LS, Vassiliou MC, Fraser SA, Stanbridge D, Ghitulescu G, Andrew CG. Proving the value of simulation in laparoscopic surgery. Ann Surg.2004;240:518-28.240518 2004 [CrossRef]

Grantcharov TP, Kristiansen VB, Bendix J, Bardram L, Rosenberg J, Funch-Jensen P. Randomized clinical trial of virtual reality simulation for laparoscopic skills training. Br J Surg.2004;91:146-50.91146 2004

Risucci D, Cohen JA, Garbus JE, Goldstein M, Cohen MG. The effects of practice and instruction on speed and accuracy during resident acquisition of simulated laparoscopic skills. Curr Surg.2001;58:230-5.58230 2001 [CrossRef]

Scott DJ, Bergen PC, Rege RV, Laycock R, Tesfay ST, Valentine RJ, Euhus DM, Jeyarajah DR, Thompson WM, Jones DB. Laparoscopic training on bench models: better and more cost effective than operating room experience? J Am Coll Surg.2000;191:272-83.191272 2000 [CrossRef]

Taffinder N, Sutton C, Fishwick RJ, McManus IC, Darzi A. Validation of virtual reality to teach and assess psychomotor skills in laparoscopic surgery: results from randomised controlled studies using the MIST VR laparoscopic simulator. Stud Health Technol Inform.1998;50:124-30.50124 1998

Stulberg SD. Computer navigation as a teaching instrument in knee reconstruction surgery. J Knee Surg.2007;20:165-72.20165 2007

Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med.2004;79(10 Suppl):S70-81.79S70 2004

Gomoll AH, Pappas G, Forsythe B, Warner JJ. Individual skill progression on a virtual reality simulator for shoulder arthroscopy: a 3-year follow-up study. Am J Sports Med.2008;36:1139-42.361139 2008 [CrossRef]

Topics

ethics ; beneficence ; cadaver ; computers ; consultant ; feedback ; hip joint ; internship and residency ; operating room ; osteotomy

First Page Preview

View Large

Username

Password

Access for Patients

Forgot Password?

Have a subscription to the print edition?

Not a Subscriber?

Buy this Article

Get online access for 30 days for $35

New to JBJS?

Subscribe to the online edition for 30 days for $75

Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.

Have a subscription to the print edition?

Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.

Activate your online account now

Forgot your password?

Enter your username and email address. We'll send you a reminder to the email address on record.

Username:*

Email Address:*

Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
by your institution, please contact you librarian or administrator for username and password information. Institutional
administrators, to reset your institution's master username or password, please contact subs@jbjs.org

References

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.

CME Activities Associated with This Article

Submit a Comment

Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

* = Required Field

Comment Author(s) * (if multiple authors, separate names by comma)

Example: John Doe

Affiliation & Institution*

Comment Title*

Comment*

Cancel

Print
PDF
Email

Recipient(s) will receive an email with a link (good for 5 days) to 'Ethical Dilemmas in Orthopaedic Surgical Training'.
Your Name:*
Example: John Doe

Email Address:* CC Me:
Enter your valid email address. Example: jdoe@example.com

Recipient's Email Address:*

Separate multiple email address with semi-colons (up to 5).

Subject:* 's The Journal of Bone & Joint Surgery: 'Ethical Dilemmas in Orthopaedic Surgical Training'
Subject for your email.

Message:

(Optional, message will truncate at 1000 characters)

Processing your request... Please Wait...

Copyright © in the material you requested is held by The Journal of Bone & Joint Surgery, Inc. (unless otherwise noted). This email ability is provided as a courtesy, and by using it you agree that that you are requesting the material solely for personal, non-commercial use, and that it is subject to Journal of Bone & Joint Surgery, Inc.'s Terms of Use. The information provided in order to email this topic will not be used to send unsolicited email, nor will it be furnished to third parties. Please refer to The Journal of Bone & Joint Surgery Inc.'s Privacy Policy for further information.

Copyright © The Journal of Bone & Joint Surgery Inc. All rights reserved.
Share
Get Citation

Graeme Holt, Tom Nunn, Alberto Gregori; Ethical Dilemmas in Orthopaedic Surgical Training. The Journal of Bone & Joint Surgery. 2008 Dec;90(12):2798-2803.

Download citation file:

RIS (Zotero)

EndNote

BibTex

Medlars

ProCite

RefWorks

Reference Manager

Copyright © The Journal of Bone and Joint Surgery, Inc.
Rights & Permissions
Article Alerts

Processing your request... Please Wait.
Submit a Comment