Document Type


Date of Degree

Spring 2019

Access Restrictions

Access restricted until 07/29/2020

Degree Name

PhD (Doctor of Philosophy)

Degree In

Biomedical Engineering

First Advisor

Anderson, Donald

Second Advisor

Thomas, Geb

First Committee Member

Grosland, Nicole

Second Committee Member

Wilder, David

Third Committee Member

Karam, Matthew


Until recently, the model for training new orthopaedic surgeons was referred to as “see one, do one, teach one”. Resident surgeons acquired their surgical skills by observing attending surgeons in the operating room and then attempted to replicate what they had observed on new patients, under the supervision of more experienced surgeons. Learning in the operating is an unideal environment to learn because it adds more time to surgical procedures and puts patients at an increased risk of having surgical errors occur during the procedure. Programs are slowly beginning to switch to a model that involves simulation-based training outside of the operating room. Wire navigation is one key skill in orthopaedics that has traditionally been difficult for programs to train on in a simulated environment. Our group has developed a radiation free wire navigation simulator to help train residents on this key skill.

For simulation training to be fully adopted by the orthopaedic community, strong evidence that it is beneficial to a surgeon’s performance must first be established. The aim of this work is to examine how simulation training with the wire navigation simulator can be used to improve a resident’s wire navigation performance. The work also examines the metrics used to evaluate a resident’s performance in a simulated environment and in the operating room to understand which metrics best capture wire navigation performance.

In the first study presented, simulation training is used to improve first year resident wire navigation performance in a mock operating room. The results of this study show that depending on how the training was implemented, residents were able to significantly reduce their tip-apex distance in comparison with a group that had received a simple didactic training. The study also showed that performance on the simulator was correlated with performance in this operating room. This study helps establish the transfer validity of the simulator, a key component in validating a simulation model.

The second study presents a model for using the simulator as a platform on which a variety of wire navigation procedures could be developed. In this study, the simulator platform, originally intended for hip wire navigation, was extended and modified to train residents in placing a wire across the iliosacral joint. A pilot study was performed with six residents from the University of Iowa to show that this platform could be used for training the other applications and that it was accepted by the residents.

The third study examined wire navigation performance in the operating room. In this study, a new metric of performance was developed that measures decision making errors made during a wire navigation procedure. This new metric was combined with the other metrics of wire navigation performance (tip-apex distance) into a composite score. The composite score was found to have a strong correlation (R squared = 0.79) with surgical experience.

In the final study, the wire navigation simulator was taken to a national fracture course to collect data on a large sample of resident performance. Three groups were created in this study, a baseline group, a group that received training on the simulator, and a third group that observed the simulator training. The results of this study showed that the training could improve the overall score of the residents compared to the baseline group. The overall distribution from resident performance between groups also shows that a large portion of residents that did not receive training came in below what might be considered as competent performance. Further studies will evaluate how this training impacts performance in the operating room.


evaluation, operating room, Orthopaedics, Surgical Skills, training, Wire Navigation


xiii, 123 pages


Includes bibliographical references (pages 99-103).


Copyright © 2019 Steven A. Long