Using Cognitive Task Analysis to train Orthopaedic Surgeons -Is it time to think differently? A systematic review

Abstract

Background:
Working time restraints; senior led care; and a reduction in 'out of hours' operating has resulted in less operating time for orthopaedic trainees in the United Kingdom. Therefore, there has been an attempt to overcome these challenges by implementing novel techniques. Cognitive Task Analysis (CTA) focuses on the mental steps required to complete complex procedures. It has been used in training athletes and in general surgery but is new to orthopaedic training.

Aim:
To undertake a systematic review to analyse if CTA is beneficial to train novice surgeons in common orthopaedic and trauma procedures.

Materials and methods:
A systematic review was performed evaluating CTA in trauma and orthopaedic surgery on MEDLINE and EMBASE. Search terms used were: 'Cognitive task', 'mental rehearsal' and 'Orthop*'']. 33 studies were originally identified. Duplicate studies were excluded (11). Articles not relating to Orthopaedic surgery were excluded (15). The CTA research ranking scale was used to evaluate the impact of the studies included.

Results:
7 studies were identified as appropriate for inclusion. 264 participants. 178 M, 86F. All studies showed objective or subjective benefits from CTA in orthopaedic training when compared to traditional methods. The majority of the participants highlighted high subjective satisfaction with the use of the CTA tools and reported that they proved to be excellent adjuncts to the traditional apprenticeship model.

Conclusion:
CTA learning tools have demonstrated significant objective and subjective benefits in trauma and orthopaedic training. It is cost effective, easily accessible and allows repeated practice which is key in simulation training.

Full text

Annals of Medicine and Surgery 59 (2020) 131–137
Available online 23 September 2020
2049-0801/© 2020 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).
Systematic Review / Meta-analysis
Using Cognitive Task Analysis to train Orthopaedic Surgeons - Is it time to
think differently? A systematic review.
Karam Ahmad
*
, Rahul Bhattacharyya, Chinmay Gupte
MSk Lab, Imperial College London, 2nd Floor, Sir Michael Uren Hub, 86 Wood Lane, London W12 0BZ, UK
ARTICLE INFO
Keywords:
Orthopaedic surgery
Simulation
Cognitive task analysis
Training
Surgical education
ABSTRACT
Background: Working time restraints; senior led care; and a reduction in ‘out of hours’ operating has resulted in
less operating time for orthopaedic trainees in the United Kingdom. Therefore, there has been an attempt to
overcome these challenges by implementing novel techniques. Cognitive Task Analysis (CTA) focuses on the
mental steps required to complete complex procedures. It has been used in training athletes and in general
surgery but is new to orthopaedic training.
Aim: To undertake a systematic review to analyse if CTA is benecial to train novice surgeons in common or-
thopaedic and trauma procedures.
Materials and methods: A systematic review was performed evaluating CTA in trauma and orthopaedic surgery
on MEDLINE and EMBASE. Search terms used were: ’Cognitive task’, ‘mental rehearsal’ and ‘Orthop*’’]. 33
studies were originally identied. Duplicate studies were excluded (11). Articles not relating to Orthopaedic
surgery were excluded (15). The CTA research ranking scale was used to evaluate the impact of the studies
included.
Results: 7 studies were identied as appropriate for inclusion. 264 participants. 178 M, 86F. All studies showed
objective or subjective benets from CTA in orthopaedic training when compared to traditional methods. The
majority of the participants highlighted high subjective satisfaction with the use of the CTA tools and reported
that they proved to be excellent adjuncts to the traditional apprenticeship model.
Conclusion: CTA learning tools have demonstrated signicant objective and subjective benets in trauma and
orthopaedic training. It is cost effective, easily accessible and allows repeated practice which is key in simulation
training.
1. Introduction
Despite changes to orthopaedic training it is well established that
current trainees have signicantly less theatre training time as
compared to their predecessors [1]. The shift from time-based to
competency-based training has worsened the current situation [1]. In an
attempt to counter both a reduction in theatre time for trainees and a
rising demand for skilled surgeons, the development of simulation as an
adjunct to the apprenticeship system has aided trainees to achieve their
required training needs.
Simulation is ‘a method or technique that is employed to produce an
experience without going through the real event’ [2]. It occurs in a safe
environment and has been shown to improve condence for surgeons
[3]. It is heavily advocated in other specialities such as Emergency
Medicine [4], General Surgery [5] and by the Royal Colleges of Surgeons
[6].
Cadaveric and virtual reality simulation has found increasing
application within orthopaedic training [7-10]. However, they are
expensive and not readily accessible. Karam et al. have shown that in the
USA, 25% of training programs do not have a dedicated simulation fa-
cility and this is due to lack of sufcient funds [11]. The situation is no
different in the UK [12]. In this setting, it is important to have a suitable
adjunct to the traditional apprenticeship model.
Cognitive Task Analysis (CTA), which originates from the military, is
a modern approach to simulation, placing emphasis on decision making
and the thought processes behind each step of key procedures [13]. It
allows trainees to learn ‘how to do’ a technical step, ‘why’ they are doing
the step and any potential errors (and solutions) that they can make in
* Corresponding author.
E-mail addresses: Karam.ahmad@doctors.org.uk, karam.ahmad@doctors.org.uk (K. Ahmad), rahulbhattacharyya09@gmail.com (R. Bhattacharyya), c.gupte00@
imperial.ac.uk (C. Gupte).
Contents lists available at ScienceDirect
Annals of Medicine and Surgery
journal homepage: www.elsevier.com/locate/amsu
https://doi.org/10.1016/j.amsu.2020.09.031
Received 17 September 2020; Accepted 20 September 2020

Annals of Medicine and Surgery 59 (2020) 131–137
132
each phase of a surgical procedure. Studies have highlighted that
mastering surgery requires a high cognitive and mental ability [14].
Fitts and Posners’s model for mastery of skill implies that cognitive
staging is the primary mental process needed for learning, followed by
associative and automated processes [15]. Skill acquisition by cognitive
methods has been shown to produce changes in the brain which engage
the primary motor complex [16].
A systematic review evaluating CTA in general surgery (2013) has
given an insight towards how CTA can improve surgical performance
[13] and in recent years CTA has been increasingly used in trauma and
elective orthopaedic training [17-19].
The aim of this study is to evaluate whether CTA learning tools are of
benet to trainees in Trauma and Orthopaedic Surgery.
2. Materials and methods
2.1. Literature search strategy
We reviewed studies on CTA in Orthopaedics on the Ovid MEDLINE
and EMBASE databases. A guide stating the research question, search
strategy, inclusion/exclusion criteria and risk of bias was formulated.
The search and screening were performed by two of the authors, and
disagreements were resolved by consensus. An electronic search was
performed on November 17, 2019. No date limitations were placed.
Only English articles were selected. Key words and phrases used were:
‘Cognitive task’ OR ‘mental rehearsal’ AND ‘Orthop*‘. Due to the limited
published data on CTA all study types and trainee ranges were consid-
ered. The studies retrieved from the search were manually reviewed to
identify other studies which could be relevant. Also reviewed were
reference lists of included studies, study registries, and grey literature.
This review has been reported in line with PRISMA (Preferred Reporting
Items for Systematic Reviews and Meta-Analyses) (Fig. 1). And
AMSTAR-2 (Assessing the methodological quality of systematic reviews)
Guidelines.
2.2. Selection, inclusion and exclusion criteria
Studies which specically analysed CTA in Orthopaedic surgery were
evaluated. We dened CTA as a method by which knowledge for a
procedure can be imparted via step by step protocols. 33 studies were
identied. De-duplication reduced this to 22. Articles not relating to
Orthopaedic surgery were excluded (15). Following inclusion/exclusion
criteria, seven published articles were considered (Fig. 1). De-
mographics of the seven studies are shown in Table 1.
Fig. 1. Prisma owchart.
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Annals of Medicine and Surgery 59 (2020) 131–137
133
2.3. Scoring of CTA studies
A 5-point scoring system to appraise CTA was developed by Wing-
eld et al. in 2015 [13]. ‘The CTA Research Ranking Scale’ assesses
journal impact score, study types and number of participants. This was
used to assess selected studies prior to further in-depth analysis. Table .2
gives an overview of ‘The CTA Research Ranking Scale’.
3. Results
3.1. Participants
264 participants across 7 studies. 178 Male and 86 Female. There
was an average of 37.7(Range:14–100) participants per study. Expertise
ranged from medical students to senior orthopaedic trainees and
consultants.
3.2. Summary of cognitive task analysis methodology and learning
principles used (Table 3)
Amer et al. [20] randomized 100 medical students to learn carpal
tunnel release surgery via video lectures or by using the Touch Sur-
gery™ [20] application. Those who had observed or participated in
Carpal tunnel release and used the app previously were excluded. The
control group watched the presentation three times in one sitting. The
intervention group completed the ‘Carpal Tunnel Surgery’ module three
times on the app. The same standardised test of 21 multiple-choice
questions was completed. The intervention group was asked to rate
the app using a 5-point Likert rating scale (ranging from very poor to
very good).
Bhattacharyya et al. [17] undertook a randomized controlled trial to
evaluate the effectiveness of the Imperial Femoral Intramedullary
Nailing Cognitive Task Analysis (IFINCTA) tool. A modied-Delphi
technique was used to design a combined written and audio-visual
tool in femoral intramedullary nailing. 22 medical students were ran-
domized in two equal groups. The intervention group were taught using
the CTA tool and the control group were given a standard operative
manual. The students were scored on MCQs and how effectively manual
steps were completed using nger swipes on the smartscreen.
Bhattacharyya et al. [18] carried out a randomized control trial to
evaluate the effectiveness of CTA in knee arthroscopy. The cognitive
task tool was developed and designed using the modied-Delphi
method. It utilized written, visual video and audiological information
simultaneously to train novices in this procedure. A double blind RCT
was then undertaken to analyse its efcacy to train novices in diagnostic
knee arthroscopy. An objective assessment using the Validated
Table 1
Study demographics.
Author Title Year No. of
Participants
Level Journal Impact
Factor
(2018)
Study
Type
Funding Source
Amer et al. A Mobile-Based Surgical Simulation
Application: A Comparative Analysis
of Efcacy Using a Carpal Tunnel
Release Module
2017 100 Medical Students J Hand Surg Am 2.090 RCT Internal
Bhattacharyya
et al.
Knee Arthroscopy Simulation A
Randomized Controlled Trial
Evaluating the Effectiveness of the
Imperial Knee Arthroscopy Cognitive
Task Analysis (IKACTA) Tool
2017 16 Novice
Orthopaedic
Trainees
The Journal of
Bone and Joint
Surgery
4.716 RCT Internal
Bhattacharyya
et al.
Trauma simulation training: a
randomized controlled trial evaluating
the effectiveness of the Imperial
Femoral Intramedullary Nailing
Cognitive Task Analysis (IFINCTA)
tool
2018 22 Medical Students Acta
Orthopaedica
3.076 RCT AO Foundation,
Switzerland,
“Multipurpose Virtual
Surgical Simulator”.
Levin et al. Pre-course cognitive training using a
smartphone application in orthopaedic
intern surgical skills “boot camps”
2018 14 Orthopaedic
Interns
Journal of
Orthopaedics
1.907 Cohort Internal
Logishetty et al. A Multicenter Randomized Controlled
Trial Evaluating the Effectiveness of
Cognitive Training for Anterior
Approach Total Hip Arthroplasty
2019 36 Surgical
Residents- Post
graduate year
1–4
The Journal of
Bone and Joint
Surgery
4.716 RCT Royal College of
Surgeons of England,
United Kingdom
CW1 Charity, United
Kingdom,
Johnson & Johnson,
Switzerland.
Sugand et al. Training effect of using Touch
Surgery™ for intramedullary femoral
nailing
2015 27 Medical Students Injury Journal 1.834 Case
Control
Internal
Sugand et al. Validating Touch Surgery™: A
cognitive task simulation and rehearsal
app for intramedullary femoral nailing
2015 39 +10 Medical Students
and Orthopaedic
Trainees
Injury Journal 1.834 Cohort Internal
Table 2
CTA research ranking scale.
Journal Impact Score (2018) Designated Point Value (1–5)
<1.5 1
1.5–2.5 2
2.5–3.5 3
3.5–4.5 4
>4.5 5
Study Type Designated Point Value (1–5)
Meta-Analysis 5
RCT 4
Cohort Study 3
Case-Control/Cross Sectional 2
Literature review 1
Number of Participants Designated Point Value (1–5)
≥500 5
100–499 4
50–99 3
10–49 2
≤9 1
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Table 3
Assessment type and associated results.
Author Year Title CTA Method Type of Assessment Results CTA
Improved
training?
Positive
Subjective
Outcome?
CTA
Research
Ranking
Amer et al. 2017 A Mobile-Based
Surgical Simulation
Application: A
Comparative Analysis
of Efcacy Using a
Carpal Tunnel Release
Module
Carpal Tunnel Surgery
steps on ‘Touch
Surgery™’ vs
Traditional Methods.
1. 21 question post-
study standardised
test
1. Test group average -
89.3% (±6.0%). Control
group average 75.6%
(±8.7%)
Yes Yes 10
2. Likert Scale for
subjective rating
2. Overall content
validity, quality of
graphics, ease of use,
and usefulness to
surgery preparation
rated as very high (4.8 of
5)
Bhattacharyya
et al.
2017 Knee Arthroscopy
Simulation A
Randomized Controlled
Trial Evaluating the
Effectiveness of the
Imperial Knee
Arthroscopy Cognitive
Task Analysis (IKACTA)
Tool
Imperial Knee
Arthroscopy Cognitive
Task Analysis (IKACTA)
tool used to describe
each phase of a
diagnostic knee
arthroscopy vs No
additional learning
material.
1. Validated
Arthroscopic Surgical
Skill Evaluation Tool
[ASSET] global
rating scale.
1. Mean ASSET score
(and standard deviation)
→IKACTA group =19.5
±3.7 points. Control
Group =10.6 ±2.3
Yes Yes 11
2. Likert Scale for
subjective rating
2. All participants
agreed that the cognitive
task analysis learning
tool was a useful
training adjunct to
learning in the operating
room.
Bhattacharyya
et al.
2018 Trauma simulation
training: a randomized
controlled trial
evaluating the
effectiveness of the
Imperial Femoral
Intramedullary Nailing
Cognitive Task Analysis
(IFINCTA) tool
Imperial Femoral
Intramedullary Nailing
Cognitive Task Analysis
(IFINCTA) tool used to
describe each phase of
antegrade femoral
intramedullary nailing
vs Standard operative
technique manual.
1. Validated “Touch
Surgery™”
application
assessment tool on
femoral
intramedullary
nailing.
1. Post-test Median
Score improvement
(Intervention group over
control group): Patient
positioning and
preparation- 20%,
Femoral Preparation-
21%, Proximal locking-
10% and Distal Locking-
19%
Yes Yes 9
2. Likert Scale for
subjective rating
2. All participants
agreed the tool made the
procedure easy to
understand. The multi-
modality approach was
benecial and that it
was benecial to use the
tool prior to operating.
10/11 participants
agreed that the tool was
easy to use and 9/11
enjoyed using the tool.
Logishetty
et al.
2019 A Multicentre
Randomized Controlled
Trial Evaluating the
Effectiveness of
Cognitive Training for
Anterior Approach
Total Hip Arthroplasty
Anterior approach Total
Hip Arthroplasty-
Participants cognitively
trained vs Training with
a standard operation
manual with surgical
video.
1. Assessment of time
taken, errors made,
prompts required and
acetabular cup
orientation.
1. Cognitive trained-
35% faster, 69% fewer
errors in instrument
selection, 92% fewer
prompts, Reduced
inclination and
anteversion errors.
Yes Yes 11
2. Training survey
assessing the
usability and
applicability of the
Cognitive Training
Tool for Learning
Total Hip
Replacement.
2. 34 of 35 residents
agreed that the CTT was
useful for understanding
technical skills, decision
making, and common
errors related to AA-
THA, was easy and
enjoyable to use, and
contributed to a marked
improvement over
standard preoperative
preparation
Levin et al. 2018 Pre-course cognitive
training using a
smartphone application
in orthopaedic intern
surgical skills “boot
camps”
Ankle open reduction +
internal xation and lag
screw xation using
‘Touch Surgery™’
1. Feedback from
participants via post
course survey
1. 10/14 participants
believed using CTA
improved baseline
understanding, 9/14
believe learning was
accelerated and 8/14
felt the application
Yes Yes 7
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Annals of Medicine and Surgery 59 (2020) 131–137
135
Arthroscopic Surgical Skill Evaluation Tool [ASSET] global rating scale
was used and a subjective assessment to evaluate participant satisfaction
was undertaken utilizing a Likert rating scale.
Levin et al. [21] had 14 Orthopaedic interns who evaluated the
Touch Surgery app: interns completed a simulated ankle
open-reduction, internal-xation and lag screw xation prior to
attending an annual four-week bootcamp. Participants completed the
learning module, and then multiple-choice questions (Pass-mark 70%).
They were required to pass the exam and allowed multiple attempts if
required. A post-course survey was provided to participants on
completion.
Logishetty et al. [19] developed procedural steps for Anterior
Approach Total Hip Arthroplasty (AA-THA) via a modied-Delphi
technique using 4 expert arthroplasty surgeons. 36 surgical residents
were block randomized in two equal groups (residents who had previ-
ously observed or performed AA-THA were excluded). The intervention
group were given online access to the cognitive tool and the control
group were given a standard operation manual for this procedure.
Sugand et al. [22] randomized 27 medical students to evaluate the
training effect of the touch surgery application in femoral intra-
medullary nailing. The students completed a pre-module questionnaire,
a test module, of which they had six attempts each and a post-module
MCQ. Scores were given for decision making, swipe interactions, and
time taken to complete steps. Percentage total scores were calculated.
Sugand et al. [23] attempted to validate Touch Surgery™ for Intra-
medullary Femoral Nailing (IFN). As per Sugand’s previous study [22],
the procedure was divided into four modules. Real-time objective per-
formance data was obtained and stored from the participants primary
attempt. This was used to assess construct validity. A post-study ques-
tionnaire using the Likert scale was used to assess face and content
validity.
3.3. Assessment and study results (Table 3)
All studies found objective or subjective benets in using CTA.
Objectively, in the study by Amer et al. [20], the intervention group
scored on average 89.3% (±6.0%) compared to 75.6% (±8.7%) on the
21 question post-study standardised test.
Both studies by Bhattacharyya et al. [17,18] found that the inter-
vention group scored higher than the control on CTA’s for f for both knee
arthroscopy and femoral nailing. For the arthroscopic Knee CTA, the
ASSET score was on average 19.5 ±3.7 for the intervention group, and
10.6 ±2.3 for the control. For the INFINCTA tool, intervention group
participants reported median post test score improvements of 20% in
Patient positioning and preparation, 21% in Femoral Preparation, 10%
in Proximal locking and 19% in Distal Locking (in comparison to control
group participants).
The study on CTA and AA-THA by Logishetty at al [19] found
cognitively trained participants were on average 35% faster, made 69%
fewer errors in instrument selection, and required 92% fewer prompts.
They also were more accurate with acetabular cup orientation.
Both studies by Sugand et al. [22,23] showed benets of CTA based
simulation for intramedullary femoral nailing. On assessing the effect of
CTA on training [22], Sugand found that novice participants improved
(following CTA based simulation) by 83% in Patient positioning and
preparation, by 94% in Femoral canal preparation, by 90% in Proximal
Table 3 (continued )
Author Year Title CTA Method Type of Assessment Results CTA
Improved
training?
Positive
Subjective
Outcome?
CTA
Research
Ranking
made the procedure
easier to learn.
Sugand et al. 2015 Training effect of using
Touch Surgery™ for
intramedullary femoral
nailing
Intra-medullary femoral
nailing on ‘Touch
Surgery™’- Consisting
of four modules,
participants completed a
pre-module MCQ, had 6
attempts at each module
and then completed a
post module MCQ.
1. Pre- and Post-
module MCQs,
Comparison of Post
module MCQ with
Experts
1. Module- (i) patient
positioning and
preparation- 83%
improvement (ii)
femoral canal
preparation- 94%
improvement (iii)
proximal locking 90%
improvement (iv) distal
locking and closure-
89% improvement. P-
Value <0.001 Similar
post module scores
between novices and
experts.
Yes N/A 6
Sugand et al. 2015 Validating Touch
Surgery™: A cognitive
task simulation and
rehearsal app for
intramedullary femoral
nailing
Intra-medullary femoral
nailing on ‘Touch
Surgery™’- Consisting
of four modules, done by
experts and novices.
1. Construct validity
using objective
metrics.
1. Experts outperformed
novices to demonstrate
construct validity.
Module - (i) Patient
positioning and
preparation- 32.5%
higher, (ii) Femoral
canal preparation-
31.5% higher, (iii)
Proximal locking- 22.5%
higher, (iv) Distal
Locking and closure -
17% higher
Yes Yes 7
2. Face and content
validity using a
subjective
questionnaire.
2. Both cohorts rated the
face validity, quality of
graphics, willingness to
use the app, usefulness
for preoperative
rehearsal as good or very
good. Experts rated the
content validity as good
too.
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Annals of Medicine and Surgery 59 (2020) 131–137
136
locking 90% and 89% in Distal locking and closure. To demonstrate
construct validity [23] experts outperformed novices in each module by
32.5% in Patient positioning and preparation, 31.5% in Femoral canal
preparation, by 22.5% in Proximal locking and by 17% Distal Locking
and closure. Levin et al. [21] did not contain any objective measure of
CTA.
Subjectively, participants from Amer et al. [20] rated content val-
idity, quality of graphics, ease of use, and usefulness to surgery prepa-
ration as very high. Bhattacharyya et al. [17,18], found that participants
agreed the cognitive task analysis learning tool was a useful training
adjunct to learning in the operating room. Over 90% of participants
found to tool easy to use and enjoyed using it. Levin et al. [21] found that
10/14 participants believed using CTA improved baseline understand-
ing, 9/14 believed learning was accelerated and 8/14 felt the procedure
was easier to learn as a result of this.
All participants in the AA-THA study by Logishetty et al. [19] found
the CTA tool useful to understand key technical steps, decision making
processes, highlighting errors, and easy to use. 34/35 enjoyed using the
tool.
When validating Touch Surgery™ for intramedullary femoral nail-
ing, Sugand et al. [23] found that both junior and senior cohorts rated
the face validity, quality of graphics, willingness to use the app, use-
fulness for preoperative rehearsal as good or very good. Experts also
rated the content validity as good.
4. Discussion
The use of CTA within orthopaedic training is relatively novel. 6/6
studies show objective benets when using CTA (one study did not use
objective assessment). They suggest CTA enhances performance and
efciency in orthopaedic training. In the randomized controlled trials by
Bhattacharyya et al. [17,18] and Logishetty et al. [19] expert created
CTA tools (using the Delphi model) have been shown to clearly improve
participants ability to complete procedures in trial scenarios. The crea-
tion of CTA tools for individual procedures can open the door to
multi-centre collaborations for other procedures and potential inclusion
in to training programs. Studies by Sugand et al. [22,23], and Amer et al.
[20] support objective and subjective benets in CTA based simulation
training.
Using CTA the trainee is able to work in a safe, protected environ-
ment, with minimal restrictions and at a time and place which suits
them. It is inexpensive, web-based and accessible that allows repetitive
practice which is the cornerstone of simulation training. Trainees can
progress faster through the initial phase of the Sigmoid learning curve
[24]. This, a concept of mathematical psychology, follows the learner
from unfamiliarity to mastery of a skill. Initially progress is slow, how-
ever with intentional practice, traction is gained, and one enters the
stage of ‘hypergrowth’ (where learning is exponential) and then subse-
quent mastery [24]. The aim of CTA is to propel the novice learner into
hypergrowth prior to getting sustained theatre experience, thereby
improving efciency of their operating theatre training time. Further-
more, this enhances patient safety as trainees are more equipped with
knowledge on the technical skills and potential errors before they
perform a procedure for the rst time on patients [17,19].
By undertaking CTA procedures, the trainee is enabled to progress
through unconscious incompetence, conscious incompetence and
potentially reach the stage of conscious competence. They, therefore,
enter the learning process on patients at a higher point on the Broadwell
learning curve [25].
Studies have estimated that 70% of vital steps can be missed out
when taught by experts [13]. This is partially attributed to expert sur-
geons being in the unconscious competence stage of teaching. CTA
provides an opportunity to rectify this aw in traditional methods of
training by being thorough and systematic.
In the current unprecedented situation due to the COVID-19
pandemic, CTA based simulation may nd an increasing role in
standardised orthopaedic training. This can be practiced remotely,
repeatedly, with no human contact. The encouraging results of this
systematic review can pave the way for future CTA based learning tools
in other areas of orthopaedics, eventually leading to formal CTA
learning programs for orthopaedic trainees worldwide.
4.1. Limitations
All studies reported thus far have not analysed transfer validity. It is
important to evaluate whether the benecial results viewed in the
simulation setting translates to patients in the operating theatre.
There may be a role for the assessment of soft skills such as
communication and leadership to be integrated into CTA.
As CTA based simulation is a developing topic there are a limited
number of studies available to include in this review. Secondary to this,
there is no clear outcome measure to evaluate CTA use between different
procedures. Variance in expertise between participants can make com-
parison between CTA based training and conventional methods difcult.
The positive ndings of all studies mean publication bias must be
considered as a potential limitation. Finally, registration of the work was
completed on Research Registry which is a smaller sized registry
compared to Prospero.
Despite limitations, CTA is a simulation tool which helps the novice
learner develop a standardised level of competence in a procedure prior
to doing it for the rst time on a patient. In healthcare systems around
the world today, the availability of such a tool is highly desirable.
4.2. Future work
Future work should focus on transfer validity of CTA to the operating
room, creation of CTA based training tools for more procedures, and
development of a clear, objective outcome measure. Once established,
the incorporation of CTA into formal teaching curriculums would
attempt to resolve some of the limitations of surgical training.
5. Conclusion
The current attempts to use CTA and other simulation methods, are
secondary to strained health services, time pressures and new legislation
reducing the time orthopaedic trainees can spend in the operating
theatre. The innovation of CTA in Orthopaedics is a systematic, cost
effective and easily accessible method of training that allows us to tackle
the challenges faced by our future surgeons.
Provenance and peer review
Not commissioned, externally peer reviewed.
Ethical approval
No ethical approval was required.
Funding
No funding was required.
Consent
None.
Registration of research studies
1. Name of the registry: Research Registry
2. Unique Identifying number or registration ID: reviewregistry948
3. Hyperlink to your specic registration (must be publicly accessible
and will be checked): https://www.researchregistry.com/browse
K. Ahmad et al.

Annals of Medicine and Surgery 59 (2020) 131–137
137
-the-registry#registryofsystematicreviewsmeta-analyses/registryofs
ystematicreviewsmeta-analysesdetails/5f1333e1daa3c40015766b0
1/
Guarantor
Karam Ahmad, Rahul Bhattacharyya and Chinmay Gupte.
CRediT authorship contribution statement
Karam Ahmad: Conceptualization, Writing - original draft,
Conception, design, review of literature, drafting and nal approval of
the paper. Rahul Bhattacharyya: Conceptualization, Writing - original
draft, Conception, design, review of literature, drafting and nal
approval of the paper. Chinmay Gupte: Conceptualization, Conception,
design and nal approval of the paper.
Declaration of competing interest
None.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.amsu.2020.09.031.
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