Advancing orthopaedic trauma care through WhatsApp:An analysis of clinical and non-clinical applications,challenges,and future directions

The integration of WhatsApp,a widely-used instant messaging application(IMA),into the realm of orthopaedics and trauma surgery has emerged as a significant development in recent years.This paper explores the multifaceted role of WhatsApp in orthopaedics,focusing on its clinical and non-clinical applications,advantages,disadvantages,and future prospects.The study synthesizes findings from various research papers,emphasizing the growing reliance on mobile technology in healthcare.WhatsApp’s role in orthopaedics is notable for its ease of use,real-time communication,and accessibility.Clinically,it facilitates triage,teleconsultation,diagnosis,treatment,patient advice,and post-operative monitoring.Non-clinically,it supports telemedicine,teleradiology,virtual frac-ture clinics,research,and education in orthopaedic surgery.The application has proven beneficial in enhancing communication among healthcare teams,providing quick responses,and motivating junior physicians.Its use in educational settings has been shown to improve learner’s understanding and patient care.However,the use of WhatsApp in orthopaedics is not without challenges.Risks include the potential spread of misleading information,privacy concerns,and issues with image quality affecting diagnosis and treatment decisions.The paper acknowledges the importance of maintaining professional boundaries and the need for oversight measures to ensure content accuracy.Looking forward,the potential of WhatsApp and similar IMAs in orthopaedics lies in their ability to streamline data collection and retrieval,improve doctor-patient communication,and address challenges like bureaucratic red tape and limited resources.The paper suggests that future orthopaedic practice,particularly in emergency departments,will increasingly rely on such technologies for efficient patient management.This shift,however,must be approached with an understanding of the ethical,legal,and practical implications of integrating social media and mobile technology in healthcare.

Patterns and Distribution of Bone Tumors among Patients at Kumi Orthopaedic Center: A Retrospective Study

Introduction: Primary bone tumors, although rare, are an important rising cause of morbidity and mortality in Africa. Late presentation, delayed diagnosis, and failure to obtain proper management are important causes of loss of limbs and lives especially in Sub-Saharan Africa. Existing data on primary bone tumors in Uganda for the various regional levels is limited. This study aimed to determine the patterns and distributions of primary bone tumors especially in rural Uganda. Methods: This was a retrospective study carried out at Kumi Orthopaedic Center from 2012 to 2023. Patients’ information regarding the histological type of bone tumor, age, sex, and tumor site was obtained from their files. Results: A total of 115 bone tumors were seen over the study period. The mean age of patients was 30 years ± 20.1 years (range: 1 to 80 years). The majority of the patients were males 67 (58.3%) and females were 48 (42.6%). Benign tumors accounted for 66 (57.4%) of the tumors while malignant tumors were 49 (42.6%). Most tumors (both benign and malignant) were found in patients between the ages of 11 to 20 years 46 (40.1%) followed by those between 21 to 30 years 15 (13.2%) and the least were in the elderly aged 71 to 80 years 4 (3.5%). The commonest benign tumors were osteochondroma 14 (21.2%), cysts 11 (16.7%), hemangiomas 9 (13.6%), and fibrous dysplasia of the bone 8 (12.1%). The commonest malignant tumors were plasmacytoma 10 (20.4%) followed by metastases 8 (16.3%), osteosarcomas 7 (14.3%), lymphoma 5 (10.2%), and fibrosarcoma 4 (8.2%). Conclusion: Uganda shares some similar epidemiological characteristics of primary bone tumors with other countries;however, this study identified some peculiar differences. Population-based studies are required to obtain more accurate epidemiological data to improve patient diagnosis and treatment.

Concept of Artificial Intelligence (AI) and Its Use in Orthopaedic Practice: Applications and Pitfalls: A Narrative Review

Background: The growth and use of Artificial Intelligence (AI) in the medical field is rapidly rising. AI is exhibiting a practical tool in the healthcare industry in patient care. The objective of this current review is to assess and analyze the use of AI and its use in orthopedic practice, as well as its applications, limitations, and pitfalls. Methods: A review of all relevant databases such as EMBASE, Cochrane Database of Systematic Reviews, MEDLINE, Science Citation Index, Scopus, and Web of Science with keywords of AI, orthopedic surgery, applications, and drawbacks. All related articles on AI and orthopaedic practice were reviewed. A total of 3210 articles were included in the review. Results: The data from 351 studies were analyzed where in orthopedic surgery. AI is being used for diagnostic procedures, radiological diagnosis, models of clinical care, and utilization of hospital and bed resources. AI has also taken a chunk of share in assisted robotic orthopaedic surgery. Conclusions: AI has now become part of the orthopedic practice and will further increase its stake in the healthcare industry. Nonetheless, clinicians should remain aware of AI’s serious limitations and pitfalls and consider the drawbacks and errors in its use.

Surgical Site Infections in Trauma and Orthopaedics at Bouaké Teaching Hospital (Côte d’Ivoire)

Background: Surgical site infections are serious healthcare problems. The aim was to describe the epidemiological, diagnostic, therapeutic, and prognostic aspects of surgical site infections in Trauma and Orthopaedics at Bouaké Teaching Hospital. Method: This retrospective, descriptive, and analytical study was conducted from January 2019 to December 31, 2021. The data studied included prevalence, initial lesions, type of surgical intervention, type of SSI, bacteria involved, treatment, and outcomes. Results: Forty-four (11%) of the 399 patients included in the study developed a surgical site infection. The mean age was 27 years, with 36 male and 8 female. Initial lesions were predominantly open fractures (n = 31;70%), with a mean delay of 48 hours for surgical management. Emergency interventions accounted for 70% (n = 31) of cases. The NNISS infection risk score was 1 in 80% (n = 35) of cases. Superficial infections (n = 34;77%) appeared early, on a mean 6 days postoperatively. Bacteriological analysis primarily identified Pseudomonas aeruginosa (n = 10;23%), sensitive to Imipenem and Chloramphenicol but resistant to Amoxicillin-clavulanic acid, Ceftriaxone, Gentamicin, and Ciprofloxacin. Multidrug-resistant bacteria were found in 89% (n = 8) of cases, with all bacteria resistant to Ceftriaxone. Surgical revision was performed in 10 patients (23%), primarily involving debridement with hardware retention (n = 7;70%). Chloramphenicol was the most commonly used antibiotic post-antibiogram (61%). Outcomes were favourable in 98% of cases. Identified risk factors included the type of lesion according to NRC classification, the delay in managing open fractures, and the NNISS score. Conclusion: The prevalence of surgical site infection was 11%, favoured by the delayed operation of open fractures.

Artificial Intelligence ChatGPT’s Perspective on Implementation of Augmented Intelligence within Orthopaedic Practice—A Comparative Narrative Synthesis?

ChatGPT has obvious benefits in the way it can interrogate vast amounts of reference information and utilise metadata generation to answer questions posed to it and is freely available having been developed through human feedback. Already there are ethical and practical implications on its impact on learning and research. Artificial Intelligence (AI) has been seen as a way of improving healthcare provision by delivering more robust outcomes but measuring these and implementing AI within this setting is at present limited and disjointed. Methods: ChatGPT was interrogated to see what it felt were the barriers to its implementation within healthcare and in particular orthopaedic practice. The evidence for this determination was then examined for validity and applicability for a practical roll out at a Trust, Regional or National level. Results: AI can synthesise a vast amount of information to help it answer specific questions. The context and structure of any question will determine the usefulness of the answer which can then be used to develop practical solutions based on experience and resource limitations. Conclusions: AI has a role in service development and can quickly focus a working group to areas to consider when practically implementing change.

Silver nanoparticle technology in orthopaedic infections

The irrational and prolonged use of antibiotics in orthopaedic infections poses a major threat to the development of antimicrobial resistance.To combat antimi-crobial resistance,researchers have implemented various novel and innovative modalities to curb infections.Nanotechnology involves doping ions/metals onto the scaffolds to reach the target site to eradicate the infective foci.In this conno-tation,we reviewed silver nanoparticle technology in terms of mechanism of action,clinical applications,toxicity,and regulatory guidelines to treat ortho-paedic infections.

Vancomycin flushing syndrome in orthopaedic practice:A case report

BACKGROUND Vancomycin flushing syndrome(VFS),also known as red man syndrome,is an allergic reaction to vancomycin.It typically presents as a rash on the face,neck,and upper torso after intravenous administration of vancomycin.VFS is blamed on rapid intravenous infusion of vancomycin during management and rarely happens after local use.A review of the literature showed that in the last 23 years,4 such cases have been reported.Here,we add another case of VFS developed after slow local absorption of vancomycin in cement beads.CASE SUMMARY A 44-year-old male with a known case of hypertension,no history of allergies to medications,and a history of chronic osteomyelitis of the right tibia with discharging sinus over the anterolateral aspect of the leg.The pus culture grew Staphylococcus aureus,which was sensitive to clindamycin and vancomycin.The patient underwent irrigation and debridement with the placement of vancomycin cement beads made from 4 g of vancomycin powder and 40 g of polymethyl methacrylate.Three hours postoperatively,the patient developed a pruritic,erythematous,macular rash predominantly on his face,neck,chest,and lower extremities and to a lesser extent his upper extremities.A diagnosis of VFS was made and was successfully treated with cetirizine(10 mg,oral)and methylprednisolone sodium succinate(125 mg,intravenous).The patient continued to have itching with a facial rash for 12 h with gradual improvement.A decision was made to not remove the beads as the patient continued to improve.Gradually,the rash disappeared after 96 h with no further sequela.CONCLUSION VFS can occur not only after rapid intravenous injection of vancomycin but also with local release,as in our case.As orthopaedic surgeons routinely use vancomycin with polymethyl methacrylate in chronic osteomyelitis and revision arthroplasty,they should be aware of such a complication occurring.

Knowledge of radiation exposure associated with common trauma imaging modalities among orthopaedic surgeons,emergency medicine physicians,and general surgeons in the United States

BACKGROUND:Few contemporary studies have assessed physicians’knowledge of radiation exposure associated with common imaging studies,especially in trauma care.The purpose of this study was to assess the knowledge of physicians involved in caring for trauma patients regarding the effective radiation doses of musculoskeletal(MSK)imaging studies routinely utilized in the trauma setting.METHODS:An electronic survey was distributed to United States orthopaedic surgery,general surgery,and emergency medicine(EM)residency programs.Participants were asked to estimate the radiation dose for common imaging modalities of the pelvis,lumbar spine,and lower extremity,in terms of chest X-ray(CXR)equivalents.Physician estimates were compared to the true effective radiation doses.Additionally,participants were asked to report the frequency of discussing radiation risk with patients.RESULTS:A total of 218 physicians completed the survey;102(46.8%)were EM physicians,88(40.4%)wereorthopaedicsurgeons,and28(12.8%)weregeneralsurgeons.Physicians underestimated the effective radiation doses of nearly all imaging modalities,most notably for pelvic computed tomaography(CT)(median 50 CXR estimation vs.162 CXR actual)and lumbar CT(median 50 CXR estimation vs.638 CXR actual).There was no difference between physician specialties regarding estimation accuracy(P=0.133).Physicians who regularly discussed radiation risks with patients more accurately estimated radiation exposure(P=0.007).CONCLUSION:The knowledge among orthopaedic and general surgeons and EM physicians regarding the radiation exposure associated with common MSK trauma imaging is lacking.Further investigation with larger scale studies is warranted,and additional education in this area may improve care.

Trends in leadership at orthopaedic surgery sports medicine fellowships

BACKGROUND Fellowship directors(FDs)in sports medicine influence the future of trainees in the field of orthopaedics.Understanding the characteristics these leaders share must be brought into focus.For all current sports medicine FDs,our group analyzed their demographic background,institutional training,and academic experience.AIM To serve as a framework for those aspiring to achieve this position in orthopaedics and also identify opportunities to improve the position.METHODS Fellowship programs were identified using both the American Orthopaedic Society for Sports Medicine and the Arthroscopy Association of North America Sports Medicine Fellowship Directories.The demographic and educational background data for each FD was gathered via author review of current curriculum vitae(CVs).Any information that was unavailable on CV review was gathered from institutional biographies,Scopus Web of Science,and emailed questionnaires.To ensure the collection of as many data points as possible,fellowship program coordinators,orthopaedic department offices and FDs were directly contacted via phone if there was no response via email.Demographic information of interest included:Age,gender,ethnicity,residency/fellowship training,residency/fellowship graduation year,year hired by current institution,time since training completion until FD appointment,length in FD role,status as a team physician and H-index.RESULTS Information was gathered for 82 FDs.Of these,97.5%(n=80)of the leadership were male;84.15%(n=69)were Caucasian,7.32%(n=6)were Asian-American,2.44%(n=2)were Hispanic and 2.44%(n=2)were African American,and 3.66%(n=3)were of another race or ethnicity.The mean age of current FDs was 56 years old(±9.00 years),and the mean Scopus H-index was 23.49(±16.57).The mean calendar years for completion of residency and fellowship training were 1996(±15 years)and 1997(±9.51 years),respectively.The time since fellowship training completion until FD appointment was 9.77 years.17.07%(n=14)of FDs currently work at the same institution where they completed residency training;21.95%(n=18)of FDs work at the same institution where they completed fellowship training;and 6.10%(n=5)work at the same institution where they completed both residency and fellowship training.Additionally,69.5%(n=57)are also team physicians at the professional and/or collegiate level.Of those that were found to currently serve as team physicians,56.14%(n=32)of them worked with professional sports teams,29.82%(n=17)with collegiate sports teams,and 14.04%(n=8)with both professional and collegiate sports teams.Seven residency programs produced the greatest number of future FDs,included programs produced at least three future FDs.Seven fellowship programs produced the greatest number of future FDs,included programs produced at least four future FDs.Eight FDs(9.75%)completed two fellowships and three FDs(3.66%)finished three fellowships.Three FDs(3.66%)did not graduate from any fellowship training program.The Scopus H-indices for FDs are displayed as ranges that include 1 to 15(31.71%,n=26),15 to 30(34.15%,n=28),30 to 45(20.73%,n=17),45 to 60(6.10%,n=5)and 60 to 80(3.66%,n=3).Specifically,the most impactful FD in research currently has a Scopus H-index value of 79.By comparison,the tenth most impactful FD in research had a Scopus H-index value of 43(accessed December 1,2019).CONCLUSION This study provides an overview of current sports medicine FDs within the United States and functions as a guide to direct initiatives to achieve diversity equality.

Investigation of litigation in trauma orthopaedic surgery

BACKGROUND It has been said that the number of orthopaedic claims has increased in the last few years. Investigation through the most prevalent cause would help to prevent further cases.AIM To review the cases of medical complaints in orthopedic patients who had been involved in a traumatic accident.METHODS A retrospective multi-center review of trauma orthopaedic-related malpractice lawsuits from 2010 to 2021 was conducted utilizing the regional medicolegal database. Defendant and plaintiff characteristics along with fracture location, allegations, and litigation outcomes were investigated.RESULTS A total of 228 claims referred to trauma-related conditions with a mean age of 31.29 ± 12.56 were enrolled. The most common injuries were at hand, thigh, elbow, and forearm, respectively.Likewise, the most common alleged complication was related to malunion or nonunion. In 47% of the cases, the main problem that led to the complaint was the inappropriate or insufficient explanation to the patient, and in 53%, there was a problem in the surgery. Eventually, 76% of the complaints resulted in a defense verdict, and 24% resulted in a plaintiff verdict.CONCLUSION Surgical treatment of hand injuries and surgery in non-educational hospitals received the most complaints. The majority of litigation outcomes were caused by a physician’s failure to fully explain and educate the traumatic orthopedic patients and technological errors.

In vitro laboratory infection research in orthopaedics:Why,when,and how

The musculoskeletal system involves multiple tissues which are constantly exposed to being exposed to various biological and mechanical stimuli.As such,isolating and studying a particular system from a complex human clinical environment is not always a realistic expectation.On top of that,recruitment limitations,in addition to the nature of orthopaedic interventions and their associated cost,sometimes preclude consideration of human trials to answer a clinical question.Therefore,in this mini review,we sought to rationalize the rapid evolution of biomedical research at a basic scientific level and explain why the perception of orthopaedic conditions has fundamentally changed over the last decades.In more detail,we highlight that the number of orthopaedic in vitro publications has soared since 1990.Last but not least,we elaborated on the minimum requirements for conducting a scientifically sound infection-related laboratory experiment to offer valuable information to clinical practitioners.We also explained the rationale behind implementing molecular biology techniques,ex vivo experiments,and artificial intelligence in this type of laboratory research.

Damage control orthopaedics: State of the art

Damage control orthopaedics(DCO) originally consisted of the provisional immobilisation of long bone-mainly femur-fractures in order to achieve the advantages of early treatment and to minimise the risk of complications, such as major pain, fat embolism, clotting, pathological inflammatory response, severe haemorrhage triggering the lethal triad, and the traumatic effects of major surgery on a patient who is already traumatised(the "second hit" effect). In recent years, new locations have been added to the DCO concept, such as injuries to the pelvis, spine and upper limbs. Nonetheless, this concept has not yet been validated in well-designed prospective studies, and much controversy remains.Indeed, some researchers believe the indiscriminate application of DCO might be harmful and produce substantial and unnecessary expense. In this respect, too,normalised parameters associated with the acid-base system have been proposed,under a concept termed early appropriate care, in the view that this would enable patients to receive major surgical procedures in an approach offering the advantages of early total care together with the apparent safety of DCO. This paper discusses the diagnosis and treatment of severely traumatised patients managed in accordance with DCO and highlights the possible drawbacks of this treatment principle.

Diabetes and its negative impact on outcomes in orthopaedic surgery

An estimated 285 million adults(aged 20-79 years)worldwide were diagnosed to have diabetes mellitus(DM)in 2010,and this number is projected to grow to 439million adults by the year 2030.Orthopaedic surgeons,regardless of their subspecialty interest,will encounter patients with DM during their career since this epidemic involves both developed and emerging countries.Diabetes results in complications affecting multiple organ systems,potentially resulting in adverse outcomes afterorthopaedic surgery.The purpose of this review is to discuss the pathophysiology of DM and its potential for impacting orthopaedic surgery patients.Diabetes adversely affects the outcome of all orthopaedic surgery subspecialties including foot and ankle,upper extremity,adult reconstructive,pediatrics,spine surgery and sports medicine.Poorly controlled diabetes negatively impacts bone,soft tissue,ligament and tendon healing.It is the complications of diabetes such as neuropathy,peripheral artery disease,and end stage renal disease which contributes to adverse outcomes.Well controlled diabetic patients without comorbidities have similar outcomes to patients without diabetes.Orthopaedic surgeons should utilize consultants who will assist in inpatient glycemic management as well as optimizing long term glycemic control.

Machine learning in orthopaedic surgery

Artificial intelligence and machine learning in orthopaedic surgery has gained mass interest over the last decade or so.In prior studies,researchers have demonstrated that machine learning in orthopaedics can be used for different applications such as fracture detection,bone tumor diagnosis,detecting hip implant mechanical loosening,and grading osteoarthritis.As time goes on,the utility of artificial intelligence and machine learning algorithms,such as deep learning,continues to grow and expand in orthopaedic surgery.The purpose of this review is to provide an understanding of the concepts of machine learning and a background of current and future orthopaedic applications of machine learning in risk assessment,outcomes assessment,imaging,and basic science fields.In most cases,machine learning has proven to be just as effective,if not more effective,than prior methods such as logistic regression in assessment and prediction.With the help of deep learning algorithms,such as artificial neural networks and convolutional neural networks,artificial intelligence in orthopaedics has been able to improve diagnostic accuracy and speed,flag the most critical and urgent patients for immediate attention,reduce the amount of human error,reduce the strain on medical professionals,and improve care.Because machine learning has shown diagnostic and prognostic uses in orthopaedic surgery,physicians should continue to research these techniques and be trained to use these methods effectively in order to improve orthopaedic treatment.

Role of decision aids in orthopaedic surgery

Medical treatment of patients inherently entails the risk of undesired complication or side effects. It is essential to inform the patient about the expected outcomes, but also the possible undesired outcomes. The patients preference and values regarding the potential outcomes should be involved in the decision making process. Even though many orthopaedic surgeons are positive towards shared decision-making, it is minimally introduced in the orthopaedic daily practice and decision-making is still mostly physician based. Decision aids are designed to support the physician and patient in the shareddecision-making process. By using decision aids, patients can learn more about their condition and treatment options in advance to the decision-making. This will reduce decisional conflict and improve participation and satisfaction.

Use of three-dimensional printing in preoperative planning in orthopaedic trauma surgery: A systematic review and meta-analysis

BACKGROUND With the increasing complexity of surgical interventions performed in orthopaedic trauma surgery and the improving technologies used in threedimensional(3D)printing,there has been an increased interest in the concept.It has been shown that 3D models allow surgeons to better visualise anatomy,aid in planning and performing complex surgery.It is however not clear how best to utilise the technique and whether this results in better outcomes.AIM To evaluate the effect of 3D printing used in pre-operative planning in orthopaedic trauma surgery on clinical outcomes.METHODS We performed a comprehensive systematic review of the literature and a metaanalysis.Medline,Ovid and Embase were searched from inception to February 8,2018.Randomised controlled trials,case-control studies,cohort studies and case series of five patients or more were included across any area of orthopaedic trauma.The primary outcomes were operation time,intra-operative blood loss and fluoroscopy used.RESULTS Seventeen studies(922 patients)met our inclusion criteria and were reviewed.The use of 3D printing across all specialties in orthopaedic trauma surgery demonstrated an overall reduction in operation time of 19.85%[95%confidence intervals(CI):(-22.99,-16.71)],intra-operative blood loss of 25.73%[95%CI:(-31.07,-20.40)],and number of times fluoroscopy was used by 23.80%[95%CI:(-38.49,-9.10)].CONCLUSION Our results suggest that the use of 3D printing in pre-operative planning in orthopaedic trauma reduces operative time,intraoperative blood loss and the number of times fluoroscopy is used.

Bibliometric analysis of research on the effects of human immunodeficiency virus in orthopaedic and trauma surgery

BACKGROUND There is little research investigating how human immunodeficiency virus(HIV)affects outcomes in orthopaedic surgery.With advances in treatment,HIV has become a chronic health problem and the chance of orthopaedic surgeons encountering it in clinical practice is increasing.AIM To ascertain the quantity and quality of peer-reviewed publications in orthopaedic journals about HIV.METHODS A search of the Web of Science database was carried out,identifying any articles relating to HIV published in orthopaedic journals.These were assessed for geographic origin and level of evidence.RESULTS Of 48.7%of orthopaedic journals listed on the Web of Science database had published articles relating to HIV.There were 168 articles about HIV in orthopaedic journals with only 40.5%(n=68)published in the time frame we analysed(January 2007 to September 2017).Very few articles came from lowincome countries and any articles published from that setting were collaborations.All of the articles were low level of evidence.CONCLUSION There is a need for more high level orthopaedic and trauma research investigating the effects of HIV,particularly research from low-income countries,where higher level research will help to guide improvements in their treatment of its musculoskeletal manifestations and complications.

A Target-Orientated Marker Image Binarization Method for Orthopaedic Surgical Navigation System

Camera calibration is the key technique in a C-arm based orthopaedic surgical navigation system. The extraction of marker location information is a necessary step in the calibration process. Ideal marker images should possess uniform background and contain marker shadow only, but in fact marker images always possess nonuniform background and are contaminated by noise and unwanted anatomic information, making the extraction very difficult. A target-orientated marker shadow extraction method was proposed. With this method a proper threshold for marker image binarization can be determined.

Use of bone marrow derived stem cells in trauma and orthopaedics: A review of current concepts

There is a considerable amount of interest in the futurerole of bone marrow-derived stem cells(BMDSCs) and tissue engineering techniques to manage conditions within the musculoskeletal system. Repair of soft tissue and bone defects, in the early stages of injury, may lead to a reduction in progression of symptoms. Furthermore, troublesome soft tissue injuries that are notoriously fraught with problems either in healing or function, could be augmented with such techniques. The aim of this review paper is to look at the advances in such strategies to tackle these problems and assess how BMDSCs, with the aid of growth factors and scaffolds, are being used in vitro, animal and even human models to treat problems within the field of trauma and orthopaedics. There is plenty of evidence that the results are encouraging and thus gaining momentum toward their use in human studies.

Orthopaedic education in the era of surgical simulation: Still at the crawling stage

Surgical skills education is in the process of a crucial transformation from a master-apprenticeship model to simulation-based training. Orthopaedic surgery is one of the surgical specialties where simulation-based skills training needs to be integrated into the curriculum efficiently and urgently. The reason for this strong and pressing need is that orthopaedic surgery covers broad human anatomy and pathologies and requires learning enormously diverse surgical procedures including basic and advanced skills. Although the need for a simulationbased curriculum in orthopaedic surgery is clear, several obstacles need to be overcome for a smooth transformation. The main issues to be addressed can be summarized as defining the skills and procedures so that simulation-based training will be most effective; choosing the right time period during the course of orthopaedic training for exposure to simulators; the right amount of such exposure; using objective, valid and reliable metrics to measure the impact of simulation-based training on the development and progress of surgical skills; and standardization of the simulation-based curriculum nationwide and internationally. In the new era of surgical education, successful integration of simulation-based surgical skills training into the orthopaedic curriculum will depend on efficacious solutions to these obstacles in moving forward.