Assessing the Successful Implementation of the Surgical Management and Reconstructive Training (SMART) Course in Nepal: Competency Test Data from Two Consecutive Years

Introduction: In low and middle-income countries (LMICs), lack of access to specialists hinders management of the severe soft-tissue injuries that accompany many fractures. Patients with such injuries then develop chronic osteomyelitis, resulting eventually in amputation. The SMART course addresses the scarcity of specialists in LMICs by teaching orthopaedic surgeons muscle and fasciocutaneous flaps. This study assesses the effectiveness of the SMART course in improving participant competency. Methods: Sixty-four orthopaedic surgeons from Nepal and Bhutan participated in the Nepal SMART course in 2016 and 2017. Demographic information was collected through a pre-course survey. A competency test with plastic and orthopaedic surgery questions from prior US in-training plastic surgery exams was administered to attendees immediately before and after the course. Data were analyzed for statistically significant differences before and after the course. Results: Overall competency test scores increased from 51.11±16.86% to 72.2±12.76% (p<0.001). Participant scores in the plastics section increased from 48.54±22.44% to 80.29±17.39% (p<0.001). The pre-course scores were higher in 2016 (mean=55.91±17.78%) compared to 2017 (mean=45.98±14.4%; p=0.021). There was a higher increase in overall test scores after the course in 2017 (mean increase=26.66±20.48%; p=0.033) compared to 2016 (mean increase=13.55±25.5%). Conclusions: These results demonstrate that the SMART course improves competency of orthopaedic surgeons in performing common lower extremity flap procedures. The course yielded significantly better results in 2017 compared to 2016, showing that the implementation of the course has been improving. Prospective studies recording short-term outcomes of flap procedures performed by participants will more directly measure the impact of the SMART course.