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Validation of a Ponseti Casting Simulation

Grant Recipient: James Barsi, MD

Stony Brook University Hospital
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Validation of a Ponseti Casting Simulation
Maria Cecilia Madariaga, B.S.; David Komatsu Ph.D.; James Barsi M.D.
Stony Brook University Hospital
Purpose:  Clubfoot is a common lower limb birth abnormality.  The gold standard for treatment is the Ponseti method which involves a series of casts that correct the deformity.  Traditional education of orthopaedic residents in the Ponseti method utilizes the apprenticeship model with learning on patients in the clinic.  With the advent of restricted training hours, simulation-based training has played an increasing role in acquiring new skills.  The purpose of this study is to validate a training program using clubfoot casting models to teach residents the Ponseti method. Primary endpoints measured will include total time to complete the task and the pressure present at the first metatarsal (FM) and talar neck (TN) after casting. Secondary endpoints will include expert evaluation using a modified objective structured assessment of technical skill (OSATS) assessing residents’ ability to effectively apply the Ponseti method and a Ponseti method task-specific checklist. This study will yield information about the formation of a replicable protocol for teaching the Ponseti method.
Methods: A standardized right clubfoot model (MD Orthopaedics Inc, Wayland IA) will be fit with two flat force-sensing receptors (FSC).  One FSR will be placed along the talar neck, and the other on the first metatarsal where cast pressure points are customarily placed. Orthopaedic residents will be asked to place a Ponseti cast and apply pressure as they normally would do.  Each attempt was graded on time to completion, a Modified objective Structured Assessment of Technical Skill (OSATS) score, and appropriate pressure measurements.  Each subject will be instructed in the Ponseti method by watching a standardized presentation.  The casting will be performed again to see if new knowledge was gained.
Results: Twelve junior (PGY 1-3) and 12 senior (PGY 4-5) residents participated in the study.  A control was performed by having a fellowship trained pediatric orthopaedic surgeon perform the task.  The control completion time was 71s.  Initial task completion were 126.6 +/- 20.5s with an OSATS of 5.4 +/-1.0 for junior residents and 109.5 +/-14.3 s with an OSATS score of 9.7 +/-1.4 for senior residents.  Following the standardized education, these improved to 115.5+/- 14.5 s with a OSATS score of 6.2 +/-1.3 for junior residents and 94.5 +/- 14.2 s with an OSATS score of 13.6 +/- 1.2 for senior residents.  Pressure measurements were markedly lower in both trainee cohorts.  Control pressure was 4 kg along the FM and 1.5 along the TN.  Among the trainees, junior residents applied an average of 0.5 and 0.5 kg at the two sites initially and 0.5 and 0.8 kg at the TN and FM respectively after the educational module.  Senior residents applied an average of 0.3 and 0.8 kg at the TN and FM initially, and 0.1 and 1.6 kg at the TN and FM following the educational module.
Conclusion:  In this era of work hour restriction there is limited direct trainee instruction in the application of a Ponseti cast.  Simulation is a tool that can be used to train procedural skills.  This study has shown that after a standardized module, all three outcome measures (task completion, OSATS score, and pressure applied) improved.  The outcome measures as initially described in the grant proposal was reached.
Future plans: This project is currently being worked on for abstract submission to POSNA’s 2021 annual meeting as well as in the drafting stages of a manuscript.