BACKGROUND The evolution of warfare has resulted in a surge of high-energy blast injuries predominantly involving the lower extremities. Once thought to impact only forward-deployed military, such mechanisms of injury are becoming a harsh reality even in civilian territory. Proficiency in surgical techniques for extremity damage control is vital for surgeons, regardless of specialty. To evaluate and train surgical residents and attending surgeons in critical limb-salvage techniques, Theater Hospital Operations Replication (THOR) has been proposed as a high-fidelity training platform to enhance extremity surgery teaching practices and assess proficiency in fasciotomy, vascular shunting, and knee-spanning external fixation in a simulated, resource-limited environment. QUESTIONS/PURPOSES Given the importance of proficiency and efficiency in surgeon ability to perform fasciotomies, vascular shunting, and placement of external fixators, in this study, we proposed two research questions: (1) Does repetition-based training within the THOR model improve surgeon knowledge and technical skill? (2) Are there differences in skill outcome when utilizing the THOR model based on surgical specialty (orthopaedic versus general) and/or level in training (attending versus resident)? METHODS This was an observational learning outcome study performed in the bioskills lab at a single institution, the Naval Medical Center Portsmouth, in which 26 surgeons completed a same-day course consisting of pretraining assessment, cadaver training on three damage-control surgery techniques in a high-fidelity THOR environment, and post-training assessment. The surgeons were either general surgeons or orthopaedic surgeons and consisted of both residents and attending surgeons. Subjects underwent a pretraining knowledge assessment, followed by two rounds of performing simulated surgery. The first round of surgery included guidance and instruction from board-certified orthopaedic surgeons. After a short break for the subjects to review the material, the second round was completed without instruction. To answer our first question of how repetition-based training impacts surgical skill, our metrics included: Objective Structured Assessment of Technical Skills (OSATS) scores (range 1 to 5, scored lowest to highest, where higher scores represent optimal skill performance), procedural accuracy, a 10-question knowledge assessment administered before and after training (scored 0 to 10, where higher scores represent competency of the anatomy and procedure steps), and total procedure time. To address our second question, data on demographic characteristics were collected on all participants, which included surgical specialty, year in training, and gender. RESULTS The general surgery residents' cohort demonstrated improvement in both mean ± SD OSATS scores (2.4 ± 0.7 before training versus 3.6 ± 0.6 after training, mean difference 1.2 [95% CI 0.4 to 2.0]; p = 0.01) and procedure duration (23 ± 7 minutes before training versus 16 ± 5 minutes after training, mean difference 6 minutes [95% CI 4 to 9]; p = 0.001) for external fixator procedures after THOR. Similar results were seen in fasciotomies after THOR. The orthopaedic surgery residents' cohort showed similar improvements in reducing procedure duration when performing knee-spanning external fixator surgery, as well as exhibited improvements during vascular shunting procedures in both mean ± SD OSATS scores (previously 3.3 ± 0.9 versus 4.0 ± 0.9, mean difference 0.7 [95% CI 0.2 to 1.2]; p = 0.01) and procedure duration (23 ± 5 minutes versus 14 ± 8 minutes, mean difference 10 minutes [95% CI 4 to 15]; p = 0.003) after THOR. When we compared the cohorts, general surgery attending surgeons demonstrated an improvement in vascular shunting procedure duration after instruction with the THOR model (19 ± 3 minutes versus 12 ± 4 minutes, mean difference 7 minutes [95% CI 1 to 13]; p = 0.03) and in overall knowledge scores (4.3 + 0.5 versus 8.0 ± 1.6, mean difference 3.8 [95% CI 0.5 to 7.0]; p = 0.04). The orthopaedic surgery attending surgeons yielded no improvement for any metric, pretraining and post-training. Using the prescores as a covariate, for almost all metrics analyzed, there were no differences between surgeon groups based on specialty after completing the repeated training. CONCLUSION Use of the high-fidelity THOR training model improved proficiency in the examined sample of extremity damage-control procedures, thus demonstrating its efficacy in enhancing surgical skills and short-interval knowledge retention while simultaneously highlighting the importance of cadaver simulation training in enhancing surgical preparedness for complex trauma. CLINICAL RELEVANCE The high-fidelity THOR training model represents a promising modality for preparing surgeons for extremity combat trauma management in resource-limited, high-stress environments. Whether in a wartime environment or in the civilian sector, efficient and skilled intervention are crucial in managing patient morbidity. Differences of a few minutes per procedure can mean all the difference in damage control, especially when compounded in situations where vascular shunting, knee-spanning external fixation, and lower leg four-compartment fasciotomy have to be performed together by both orthopaedic and general surgeons. The observational period in this study spanned 1 day and thus does not provide information on retention of long-term skills or knowledge. A follow-on study can assess how time from initial training to final evaluation impacts overall skill competency and knowledge.

中文翻译：

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高保真模型中基于重复的培训能否同样提高学员和主治外科医生的关键创伤外科技能？


背景技术战争的演变导致高能爆炸伤激增，主要涉及下肢。人们一度认为这种伤害机制只会影响前沿部署的军队，但即使在民用领域，这种伤害机制也正在成为严酷的现实。无论专业如何，熟练掌握肢体损伤控制的外科技术对于外科医生来说都至关重要。为了评估和培训外科住院医生和主治外科医生关键的保肢技术，剧院医院手术复制 (THOR) 被提议作为高保真培训平台，以加强四肢外科教学实践并评估筋膜切开术、血管分流术和膝关节的熟练程度-在模拟的、资源有限的环境中跨越外固定。问题/目的鉴于外科医生执行筋膜切开术、血管分流和放置外固定器的熟练程度和效率的重要性，在本研究中，我们提出了两个研究问题：(1) THOR 模型中基于重复的训练是否可以提高外科医生的能力知识和技术技能？ (2) 使用基于外科专业（骨科与全科）和/或培训水平（主治与住院医师）的 THOR 模型时，技能结果是否存在差异？方法 这是一项在朴茨茅斯海军医疗中心的生物技能实验室进行的观察性学习结果研究，其中 26 名外科医生完成了当天的课程，包括培训前评估、三种损伤控制手术技术的尸体培训。高保真THOR环境和训练后评估。外科医生要么是普通外科医生，要么是整形外科医生，由住院医师和主治外科医生组成。 受试者接受训练前知识评估，然后进行两轮模拟手术。第一轮手术包括经过委员会认证的骨科医生的指导和指导。经过短暂的休息让受试者复习材料后，第二轮在没有指导的情况下完成。为了回答我们的第一个问题，即基于重复的训练如何影响手术技能，我们的指标包括：技术技能客观结构化评估 (OSATS) 分数（范围 1 到 5，分数最低到最高，其中较高分数代表最佳技能表现）、程序性评估准确性、培训前后进行的 10 个问题知识评估（评分为 0 到 10，其中较高的分数代表解剖学和手术步骤的能力）以及总手术时间。为了解决我们的第二个问题，我们收集了所有参与者的人口特征数据，其中包括外科专业、培训年份和性别。结果 普外科住院医师队列显示，平均±SD OSATS 评分（训练前为 2.4 ± 0.7，训练后为 3.6 ± 0.6，平均差 1.2 [95% CI 0.4 至 2.0]；p = 0.01）和手术持续时间（23训练前 ± 7 分钟与训练后 16 ± 5 分钟相比，THOR 后外固定器手术的平均差异为 6 分钟 [95% CI 4 至 9]； THOR 后的筋膜切开术也出现了类似的结果。骨科住院医师队列在进行跨膝外固定器手术时在缩短手术时间方面表现出类似的改善，并且在血管分流手术期间在平均±SD OSATS评分上也表现出改善（之前为3.3±0.9与4.0±0.9，平均差值） 0.7 [95% CI 0.2 至 1.2]；p = 0。01) 和 THOR 后手术持续时间（23 ± 5 分钟与 14 ± 8 分钟，平均差异 10 分钟 [95% CI 4 至 15]；p = 0.003）。当我们比较队列时，普通外科主治外科医生在接受 THOR 模型指导后证明血管分流手术持续时间有所改善（19 ± 3 分钟与 12 ± 4 分钟，平均差异 7 分钟 [95% CI 1 至 13]；p = 0.03）和总体知识得分（4.3 + 0.5 与 8.0 ± 1.6，平均差 3.8 [95% CI 0.5 至 7.0]；p = 0.04）。骨科主治医生在训练前和训练后的任何指标上都没有取得任何改善。使用预评分作为协变量，对于几乎所有分析的指标，完成重复训练后，基于专业的外科医生组之间没有差异。结论 使用高保真 THOR 训练模型提高了四肢损伤控制程序检查样本的熟练程度，从而证明了其在提高手术技能和短时间间隔知识保留方面的功效，同时强调了尸体模拟训练在增强手术准备方面的重要性对于复杂的创伤。临床相关性 高保真 THOR 训练模型代表了一种很有前途的模式，可以帮助外科医生在资源有限、高压力的环境中进行四肢战斗创伤处理。无论是在战时环境还是在民用部门，高效且熟练的干预对于控制患者发病率至关重要。 每次手术几分钟的差异可能意味着损伤控制的所有差异，特别是在血管分流、跨膝外固定和小腿四室筋膜切开术必须由骨科医生和普通外科医生一起进行的情况下。本研究的观察期为 1 天，因此不提供有关长期技能或知识保留的信息。后续研究可以评估从初始培训到最终评估的时间如何影响整体技能能力和知识。