Assessment of competence in antegrade intramedullary nail osteosynthesis of femoral shaft fractures: A global Delphi consensus study

Introduction
Antegrade intramedullary nailing of femoral shaft fractures (FSF) is a core competency in orthopedic surgery. However, trainees’ skills acquisition is hindered due to reduced exposure to the procedure. Competency-based medical education (CBME) and simulation-based training (SBT) offer an alternative to traditional time-based residency models; however, their implementation in FSF fixation requires assessment tools supported by validity evidence. This study aimed to use the Delphi method to establish consensus regarding assessment parameters for antegrade FSF nailing.

Materials and methods
A modified Delphi study was conducted with a global panel of AO trauma faculty educators. In round 1, panelists proposed key technical skills and common errors during FSF fixation. Round 2 involved rating parameter importance on a 5-point Likert-like scale. In Round 3, specific score ranges were determined for a specific fracture model; these results are not presented in this study. In the final round, each parameter was assigned a weight from 1 to 10. Pearson's correlation coefficient was calculated between round 2 and the final round.

Results
Of 98 panelists included, 87 actively participated. Round 1 yielded 37 parameters. Consensus was reached for 34 after round 2. The mean importance rating in round 2 was 4.04 (SD 0.34), and the mean weight rating in the final round was 8.56 (SD 0.62). A strong correlation was found between importance and weight ratings (r = 0.94, p < 0.001). The final 34 parameters cover the entire fixation process, with 2 relating to fracture reduction, 6 to guidewire placement and entry point, 4 to reaming, 3 to nail choice, 6 to nail placement, 9 to interlocking, and 4 to the end of the procedure.

Discussion
This study defined 34 expert-derived parameters for intramedullary FSF fixation. They are well-suited for implementation in CBME programs and simulators, ensuring content validity and supporting structured skills training.