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Training and Transfer Effect of FluoroSim, an Augmented Reality Fluoroscopic Simulator for Dynamic Hip Screw Guidewire Insertion

A Single-Blinded Randomized Controlled Trial

Sugand, Kapil Pg CHBE, BSc, MRCS1,2; Wescott, Robert A. BSc3; Carrington, Richard FRCS2; Hart, Alister MA, MD, FRCS2,3; van Duren, Bernard H. DPhil, CEng, MIMechE, MRCS3,4

doi: 10.2106/JBJS.18.00928
Topics in Training

Background: FluoroSim, a novel fluoroscopic simulator, can be used to practice dynamic hip screw (DHS) guidewire insertion in a high-fidelity clinical scenario. Our aim was to demonstrate a training effect in undergraduate medical students who are not familiar with this operation and its simulation.

Methods: Forty-five undergraduate medical students were recruited and randomized to either training (n = 23) or control (n = 22) cohorts. The training cohort had more exposure to FluoroSim (5 attempts each week) over a 2-week period (with a 1-week washout period in between) compared with the control cohort (a single attempt 1 week apart) over a 2-week period. Five real-time objective performance metrics were recorded: (1) tip-apex distance (TAD) (mm), (2) predicted cut-out rate (%), (3) total procedural time (sec), (4) total number of radiographs (n), and (5) total number of guidewire retries (n).

Results: At baseline, there was no significant difference in the performance metrics, which confirmed the absence of a selection bias. The intragroup training effect demonstrated a significant improvement in all metrics for the training cohort only. A significant difference between groups was demonstrated as the training cohort significantly outperformed the control cohort in 3 metrics (procedural time [25%], number of radiographs [57%], and number of guidewire retries [100%]; p < 0.001). A learning curve showed an inversely proportional correlation between frequency of attempts and procedural time as well as the number of digital fluoroscopic radiographs that were made, indicating the development of psychomotor skills. There was also an improved baseline of the learning curve after the 1-week washout period, suggesting skill retention.

Conclusions: Skill acquisition with the FluoroSim system was demonstrated with repeat exposure in a safe, radiation-free high-fidelity clinical simulation with actual operating room equipment. The task of DHS guidewire insertion requires cognitive and psychomotor skills that take a variable number of attempts to acquire, as demonstrated on the learning curve. Additional work is required to demonstrate that the skill tested by the FluoroSim is the same skill that is required for intraoperative DHS guidewire insertion. However, use of the FluoroSim provides improvement in skills with extra-clinical training opportunities for orthopaedic trainees.

Clinical Relevance: FluoroSim has demonstrated validity and training effect. It has the potential to be approved for possible use on patients in the operating room to help surgeons with the operation. Consequently, operating time, accuracy of TAD, and surgical outcomes may all be improved.

1MSk Lab, Imperial College London, London, United Kingdom

2Royal National Orthopedic Hospital, Stanmore, United Kingdom

3Institute of Orthopedics & Musculoskeletal Sciences, University College London, London, United Kingdom

4Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), School of Medicine, University of Leeds, Leeds, United Kingdom

E-mail address for K. Sugand:

Investigation performed at the Royal National Orthopedic Hospital, Stanmore, United Kingdom

Disclosure: This project was funded by the Professor A.T. Fripp Fund. B.H.v.D. is a clinical fellow funded by the National Institute for Health Research. R.A.W. received a bursary from the Goldberg Schachmann and Freda Becker Memorial Fund. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (

Copyright © 2019 by The Journal of Bone and Joint Surgery, Incorporated
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