Cognitive task analysis (CTA) in orthopaedics: From novelty to necessity

By Saran Singh Gill^a, Karam Ahmad^a,b, Chinmay Madhukar Gupte^a,c,d and Rahul Bhattacharyya^a,e

^aDepartment of Surgery and Cancer, Imperial College London, London, UK
^bManchester University NHS Foundation Trust, Manchester, UK
^cImperial College Healthcare NHS Trust, London, UK
^dFounder: Sportshealing Clinic, London, United Kingdom
^eNHS Lanarkshire University Hospitals, Glasgow, UK

Cognitive Task Analysis (CTA) has steadily moved from a niche concept within medical education to a practical, evidence-supported method of improving surgical training¹. CTA breaks down procedures into their cognitive components, including decision points, errors and solutions, and the reasoning behind each manoeuvre. Today, the pressures affecting surgical training, shift to competency based training, changes in operative practice, and the rapid diversification of technology in theatres demand that we reconsider CTA not as an adjunct, but as an essential component of modern orthopaedic curricula^2,3.

A prior review examining CTA in Orthopaedics identified seven studies, involving 264 participants across knee arthroscopy, carpal tunnel release, femoral nailing, and anterior approach total hip arthroplasty⁴. The findings were remarkably consistent, finding that CTA led to measurable improvements in performance, efficiency, and procedural understanding across all procedures reviewed. Studies deploying expertly designed CTA tools, often constructed using modified Delphi consensus, reported that trainees performed procedures faster, made fewer errors, required fewer prompts, and demonstrated improved decision-making⁴. Subjectively, trainees repeatedly described CTA tools as clear, enjoyable, and valuable adjuncts to clinical learning. Even simple smartphone-based platforms, such as Touch Surgery™, produced improvements in knowledge and procedural accuracy⁴. Yet, the review also found that transfer validity remained untested, the number of CTA modules was small, and outcome measures were inconsistent across studies. CTA’s potential was evident, but its place in training remained undefined⁴. Since then, further validation studies, including randomised controlled trials, have provided significant evidence that CTA can improve both trainee confidence and procedural skill^5-10. The question now is whether the landscape of Orthopaedics has evolved sufficiently for CTA to become embedded within the training framework.

The training environment in 2025: How does CTA fit?

Persistent reduction in operative exposure

The factors that originally drove interest in simulation, reduced time in theatre, working time directives, rota gaps, and service pressures, have not eased^11-14. Many trainees still report difficulty accessing cases consistently, and early-stage exposure to common trauma procedures remains highly variable across the UK¹⁵. While the consolidation of specialist services has improved patient outcomes, it has also concentrated operative experience in ways that may disadvantage trainees in peripheral centres. CTA offers a reliable, standardised method of cognitive rehearsal that can help level this playing field.

Simulation inequity and cost barriers persist

Many training programmes may not have dedicated simulation facilities owing to cost constraints. High-fidelity VR arthroscopy and arthroplasty simulators cost tens of thousands of pounds. Robotic simulators are even more expensive, often available only in centres with research funding or industry partnerships. CTA, in contrast, is accessible, scalable, and inexpensive. Tools can be delivered on any digital device, from a desktop computer to a smartphone. For trusts unable to invest heavily in simulation infrastructure, CTA offers an equitable alternative that can still achieve significant learning gains. It can also support standardised teaching across regions, deaneries, and hospital groups.

A tool for international standardisation

CTA’s portability gives it international relevance. In low- and middle-income countries where cadaveric training or high-fidelity VR simulation may be impractical, CTA provides a low-cost method for ensuring trainees learn safe, stepwise approaches to essential procedures. During global disruptions, such as the COVID-19 pandemic, simulation-based training demonstrated its value as a method of remote, contact-free training^16-17. As international fellowship pathways expand, CTA could also help align expectations of procedural knowledge between countries, facilitating global mobility and raising minimum training standards.

Integrating CTA into modern orthopaedic curricula

Embedding CTA Into national training frameworks

CTA naturally aligns with the structure of the trauma and orthopaedic curriculum, particularly with procedure-based assessments (PBAs) and critical competence milestones^18-19. A CTA module could serve as a prerequisite before a trainee’s first supervised attempt at a new operation, ensuring foundational knowledge long before they step into theatre. Bootcamps for new registrars, simulation days, and structured teaching sessions could incorporate CTA modules to ensure consistency across training posts.

Optimising the learning curve: Cognitive before technical

Mastering a procedure requires both cognitive and psychomotor skill. CTA strengthens the cognitive scaffold upon which technical practice is built^20-21. By allowing trainees to reach the 'conscious competence' stage before entering theatre, CTA enhances early performance and accelerates progression along the learning curve. It also allows any potential cadaveric simulation time to be used more efficiently because trainees arrive with a strong conceptual understanding.

Portfolio evidence and tracking progress

CTA modules, if appropriately advanced and integrated into a decision tree-based format, can generate objective metrics, including error identification, decision accuracy, and sequential reasoning. These outputs align well with the competency-based structure of modern training portfolios, providing evidence of preparation, progress, and reflective learning.

Limitations and unresolved questions

Despite its advantages, CTA is not a complete solution. Transfer validity, the extent to which CTA-induced gains translate to operative performance, remains underexplored. Studies to date have been small and procedure specific. CTA modules require careful construction to avoid oversimplification or inaccurate representation of procedural nuance. And CTA must complement, not replace, clinical exposure and supervised operative experience. Standardisation of CTA methodology, outcome measures, and integration strategies will be essential as adoption increases.

Future directions

Future research should prioritise large-scale, multicentre randomised controlled trials to determine whether improvements gained through CTA translate into measurable enhancements in operative performance and patient outcomes. Standardisation of CTA methodology, outcome metrics, and validation frameworks is needed to ensure reproducibility and comparability across centres. There is also a clear opportunity to integrate CTA more formally into national training curricula, including its incorporation into robotic surgery pathways, supported by the development of expert-derived and openly accessible CTA libraries that align with competency requirements. Research should further expand the application of CTA to non-technical skills such as situational awareness, leadership, communication, and decision-making in high-pressure environments. In addition, combining CTA with other educational modalities, including virtual reality simulation, cadaveric training, and structured intraoperative coaching, may provide a comprehensive and scalable model for optimising the surgical learning curve.

Conclusion

In the current climate and training pressure, the case for CTA has strengthened considerably. It is cost-effective, scalable, evidence-supported, and well aligned with the realities of modern surgical training. As pressure on clinical exposure continues and technology transforms operative practice, CTA offers trainees a reliable method for developing procedural understanding and decision-making long before they touch an instrument. It is an essential tool for a training landscape that demands efficiency, equity, and adaptability.

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