Bonedoc is a serious game. Developed for the purpose of improving surgery. Though hopefully it is accesible to those who are considering a career in Orthopaedics in the future.
It is an implementation of 'See One, Do One, Teach One' in that you can watch the clips on this site to decide if you want to buy the app,
Then I trust you will perform the surgery at least once before you teach a friend how to virtually operate.
This is a view which shows what the typical medical student or junior doctor sees. Hardly helpful in learning the key concepts of the surgery. but in the app you get to operate.
The impetus for the game came from having the experience of operating on patients, and being aware that interpreting x-ray images and consequently how to adjust the trajectory of my drill,or guidewire was not necessarily the best way to learn the surgical craft.
We trust that the experience will be rich enough, that perhaps in the future, you will need to prove your virtual skills on the app, before you operate on my relative.
Screw and plate fixation of hip fractures is one of the first surgical procedures which trainees will perform. It is also one of the first times they need to use X-rays which provide a 2-dimensional picture of the 3 dimensional location and angle of the wires,screws and plates used to fix the fracture.
The app allows you to perform all the relevant tasks to pinning a hip fracture, from fracture reduction (aligning the parts of the bone), making an incision (cutting the skin), placing the guidewire, over which a screw is placed.
This image shows a stage in the procedure where you can see the fracture, as well as the guidewire,which is being held in place by the guide-plate.
The guideplate allows you to be sure your final plate will sit flush with the bone.
The guide-plate you would use in the real world guides your placement of the wire and screws, and then finally you have to fill the lag screws. At the conclusion of the operation you get to do an instant virtual dissection to see exactly where you have placed the screw and plate. Something impossible in the real world.
Finally you get comprehensive results. Which will improve your surgery, but initally you will probably only look at the bottom line.
Feedback in the real world can be hard to get. X-rays can make your screw appear to be close to acceptable, but in reality they may lie close to the joint.
Bonedoc gives you feedback which has real world meaning, such as the location of the screw tip, in relation to the 'ideal' sweetspot. But which would not be achievable unless you took a CT Scan.
There is nothing like competition to improve performance. The app hooks into the Game Center, so you can challenge your colleagues and friends, and see whom is the best local or global Bonedoc.
It is also easy to share your triumphs via Facebook or Twitter.
We hope you have fun. And for those who are actually doing the real surgery, we hope that by playing the app, your real world performance, and subsequently the care of your patients will improve.
A 'broken hip' usually refers to a fracture of the femoral neck. It is one of the most common orthopaedic operations. It is one of the first procedures in which a trainee has to use X-ray guidance.
Patients are often elderly, so a short well-performed operation offers the best chance of getting patients back on their feet, and into life.
Why is there no button to restart the procedure?
For the same reason there is no similar button in a real operating theatre!
It's not how you get yourself into trouble. It's how you get yourself out of trouble!
If things are really bad, You can force-close the app.
Why was the app developed?
To help real patients get a better operation.
Practice makes perfect, and there is no better time to 'get your eye in' than while waiting for the anaesthetic team to get ready.
If the app gets used by a teenager, who becomes inspired to become a surgeon, and has already started to hone their skills. The patient wins.
Why not make it free?
Income generated from sales goes towards supports further app development, as well as supporting other research at the university.
The iOS platform, with consistent hardware and operating system is most easily supported for our small development team.
Your Learning Curve can be compared with your friends by seeing your scores in your first 10 and first 100 procedures on the game center leaderboard
Effortful Labor. If it takes 10 years to master any field (Simon as quoted by Ross). Then peforming multiple operations with appropriate feedback on the app should up your game without spending nights and weekends in the Operating Room.
Ross, P. E. (2006). The expert mind. Sci Am, 295(2), 64-71.
Challenge. Perform a successful operation through a minimal incision, and you can challenge your friends in the game center. There are multiple other achievements (which are hidden but hints are in other parts of this section)
Aligning the parts of the fracture anatomically, will get you a higher score. But each time you adjust the traction away from the correct direction will decrease your score. Think before you shift the traction. Different planes on the traction is more evident on either the 'AP' or 'Lat' view on the X-ray. In the Real world a Poor reduction = More chance of failure of fixation.
A smaller incision will get higher points. Multiple changes of the incision length cuts down your score.
Smaller incision = Less chance of infection.
Can you do the operation without making an incision?
Drilling the guidewire into the hip joint is poor practice, as it will affect the joint cartilage, Your score will suffer.
While the guidewire is only millimeters thick, repeated repositionings and re-angulation will weaken the bone, especially osteoporotic bones. Consequently your score will weaken too.
The 'Dog-Leg' is a measure of the ability to identify the projected trajectory of a guide-wire and make the appropriate correction. Mistakenly placed wires in all directions will raise the 'Dog-Leg' and subsequently lower your score.
The ideally placed screw is 5mm short of the articular surface, in line with the femoral neck and passing through the midpoint of the round femoral head. Can you hit the 'sweetspot'.
A screw which is superior, anterior and long is significantly worse than the opposite (inferior, posterior or short). Screws which cut-out and enter the hip hoint go in the superior, anterior direction.
The Tip Apex Distance has been correlated with the tendency for failure of the procedure. The ideal is less than 25mm.
Baumgaertner, M. R., Curtin, S. L., Lindskog, D. M., & Keggi, J. M. (1995). The value of the tipapex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am, 77(7), 1058-1064.
The ideal plate should sit flush on the bone. You will notice the app automatically pushed the guide-plate out till it sits flush. If the plate is not sitting on the bone, screws placed can cause loss of position of the fracture, or the lag screws to cut out.
Flare of Greater Trochanter
After several operations you will hopefully notice how changing your entry position affects the angle of the screw as the screw/plate angle is 135 degrees
The ideal lag screws should pass through the far cortex by a couple of millimetres (bicortical fixation).
They should exit at 0 degrees to the bone (orthogonal).
Taking more X-rays exposes the patient (and the surgical team) to more radiation. But screw position is more important than an extra X-ray.
Swapping between 'AP' and 'Lat' views generally takes around 30 seconds, which will affect your time-score (also possibly contributes to increased infection risk.
Long operation times are associated with getting cold, increased blood loss, increased infection risk, increased anesthetic.
A faster operation, (but done well) is better than a slower operation, so you will get more points.