Novel immersive virtual reality (IVR) technologies are revolutionizing medical education. Virtual anatomy education using head-mounted displays allows users to interact with virtual anatomical objects, move within the virtual rooms, and interact with other virtual users. While IVR has been shown to be more effective than textbook learning and 3D computer models presented in 2D screens, the effectiveness of IVR compared to cadaveric models in anatomy education is currently unknown. In this study, we aim to compare the effectiveness of IVR with direct cadaveric bone models in teaching upper and lower limb anatomy for first-year medical students. A randomized, double-blind crossover non-inferiority trial was conducted. Participants were first-year medical students from a single University. Exclusion criteria included students who undertook prior undergraduate or graduate degrees in anatomy. In the first stage of the study, students were randomized in a 1:1 ratio to IVR or cadaveric bone groups studying upper limb skeletal anatomy. All students were then crossed over and used cadaveric bone or IVR to study lower limb skeletal anatomy. All students in both groups completed a pre-and post-intervention knowledge test. The educational content was based on the University of Toronto Medical Anatomy Curriculum. The Oculus Quest 2 Headsets (Meta Technologies) and PrecisionOS Anatomy application (PrecisionOS Technology) were utilized for the virtual reality component. The primary endpoint of the study was student performance on the pre-and post-intervention knowledge tests. We hypothesized that student performance in the IVR groups would be comparable to the cadaveric bone group. 50 first-year medical students met inclusion criteria and were computer randomized (1:1 ratio) to IVR and cadaveric bone group for upper limb skeletal anatomy education. Forty-six students attended the study, 21 completed the upper limb modules, and 19 completed the lower limb modules. Among all students, average score on the pre-intervention knowledge test was 14.6% (Standard Deviation (SD)=18.2%) and 25.0% (SD=17%) for upper and lower limbs, respectively. Percentage increase in students’ scores between pre-and post-intervention knowledge test, in the upper limb for IVR, was 15 % and 16.7% for cadaveric bones (p = 0. 2861), and for the lower limb score increase was 22.6% in the IVR and 22.5% in the cadaveric bone group (p = 0.9356). In this non-inferiority crossover randomized controlled trial, we found no significant difference between student performance in knowledge tests after using IVR or cadaveric bones. Immersive virtual reality and cadaveric bones were equally effective in skeletal anatomy education. Going forward, with advances in VR technologies and anatomy applications, we can expect to see further improvements in the effectiveness of these technologies in anatomy and surgical education. These findings have implications for medical schools having challenges in acquiring cadavers and cadaveric parts

Novel immersive virtual reality (IVR) technologies are revolutionizing medical education. Virtual anatomy education using head-mounted displays allows users to interact with virtual anatomical objects, move within the virtual rooms, and interact with other virtual users. While IVR has been shown to be more effective than textbook learning and 3D computer models presented in 2D screens, the effectiveness of IVR compared to cadaveric models in anatomy education is currently unknown. In this study, we aim to compare the effectiveness of IVR with direct cadaveric bone models in teaching upper and lower limb anatomy for first-year medical students. A randomized, double-blind crossover non-inferiority trial was conducted. Participants were first-year medical students from a single University. Exclusion criteria included students who undertook prior undergraduate or graduate degrees in anatomy. In the first stage of the study, students were randomized in a 1:1 ratio to IVR or cadaveric bone groups studying upper limb skeletal anatomy. All students were then crossed over and used cadaveric bone or IVR to study lower limb skeletal anatomy. All students in both groups completed a pre-and post-intervention knowledge test. The educational content was based on the University of Toronto Medical Anatomy Curriculum. The Oculus Quest 2 Headsets (Meta Technologies) and PrecisionOS Anatomy application (PrecisionOS Technology) were utilized for the virtual reality component. The primary endpoint of the study was student performance on the pre-and post-intervention knowledge tests. We hypothesized that student performance in the IVR groups would be comparable to the cadaveric bone group. 50 first-year medical students met inclusion criteria and were computer randomized (1:1 ratio) to IVR and cadaveric bone group for upper limb skeletal anatomy education. Forty-six students attended the study, 21 completed the upper limb modules, and 19 completed the lower limb modules. Among all students, average score on the pre-intervention knowledge test was 14.6% (Standard Deviation (SD)=18.2%) and 25.0% (SD=17%) for upper and lower limbs, respectively. Percentage increase in students’ scores between pre-and post-intervention knowledge test, in the upper limb for IVR, was 15 % and 16.7% for cadaveric bones (p = 0. 2861), and for the lower limb score increase was 22.6% in the IVR and 22.5% in the cadaveric bone group (p = 0.9356). In this non-inferiority crossover randomized controlled trial, we found no significant difference between student performance in knowledge tests after using IVR or cadaveric bones. Immersive virtual reality and cadaveric bones were equally effective in skeletal anatomy education. Going forward, with advances in VR technologies and anatomy applications, we can expect to see further improvements in the effectiveness of these technologies in anatomy and surgical education. These findings have implications for medical schools having challenges in acquiring cadavers and cadaveric parts

INTRODUCTION. Simulation plays an important role in surgical education and the ability to perfect surgical performance. Simulation can be enhanced by adding various layers of realism to the experience. Haptic feedback enhances the simulation experience by providing tactile responses and virtual reality imagery provides an immersive experience and allows for greater appreciation of three-dimensional structures. In this study, we present a proof-of-concept haptic simulator to replicate key steps of a cervical laminoplasty procedure. The technology uses affordable components and is easily modifiable so that it can be used from novice through to expert level. Custom models can be easily added ensuring the simulator can be used in a wide range of orthopaedic applications from baseline education through to day of surgery pre-operative simulation. METHOD. We used the Unity Game Engine, the 3D Systems “Touch” Haptic Feedback Device (HFD), and a Meta Quest VR headset. Our system uses a number of complex algorithms to track the shape and provide haptic feedback of a virtual bone model. This allows for simulation of various tools including a high-speed burr, Kerrison rongeur and intraoperative X-rays. RESULTS. Our simulator replicates the tactile sensations of bone-burring tasks. Although we focused on the cervical laminoplasty procedure, the system can load data from CT scans, enabling the simulation of multiple other procedures. The parts cost of our system, $10,000 NZD, is a fraction of the cost of traditional surgical simulators. DISCUSSION. Our simulator reduces financial barriers to accessing orthopaedic simulators. Trainees can perform hands-on practice without compromising patient safety. The immersive nature of VR, combined with realistic haptic feedback, enables trainees to develop the dexterity and three-dimensional understanding of detailed bony work. Further refinements are needed before we can perform validation studies on our system. CONCLUSIONS. We present an affordable surgical simulator capable of simulating bony surgical procedures in a VR environment using haptic feedback technology and consumer-grade components. ACKNOWLEDGEMENTS. This research was made possible by the generosity of the Wishbone Trust

Introduction. The efficacy of Virtual Reality (VR) as a teaching augment for arthroplasty has not been well examined for unfamiliar multistep procedures such as unicompartmental knee arthroplasty (UKA). This study sought to determine if VR improves surgical competence over traditional procedural preparation when performing a UKA. Methods. 22 Orthopaedic trainees were randomized to training sessions: 1) “VR group” with access to an immersive VR learning module that had been designed in conjunction with the manufacturer or 2) “Guide group” with access to manufacture's technique guide and surgical video. Both groups then performed a full UKA on SawBones models. Surgical competence was assessed via Objective Structures Assessment of Technical Skills (OSATS) validated rating system (max 25 points). Results. Participants equally distributed all training levels between groups. There was no difference in surgical times between VR and Guide groups (VR=43.0 vs Guide=42.4 mins; p=0.9). There was no difference in total OSATS score between groups (VR=14.2 vs Guide=15.7; p=0.59). There was also no difference between groups when sub-analysis was performed by training level. Most felt VR would be a useful tool for resident education (77%) and reported a likeliness to utilize VR for case preparation if available (86.4%). Conclusion. In a randomized controlled trial for trainees performing a complex, unfamiliar procedure (UKA), VR training demonstrated equivalent surgical competence to traditional technique guides and videos. Despite this, the majority of trainees find the technology beneficial and would use it if available. This project suggests as currently constructed, VR should be incorporated as an adjunct, rather than a replacement, to traditional surgical preparation/training methods

Background. Revision total knee arthroplasty (rTKA) is a high stakes procedure with complex equipment and multiple steps. For rTKA using the ATTUNE system revising femoral and tibial components with sleeves and stems, there are over 240 pieces of equipment that require correct assembly at the appropriate time. Due to changing teams, work rotas, and the infrequency of rTKR, scrub nurses may encounter these operations infrequently and often rely heavily on company representatives to guide them. In turn, this delays and interrupts surgical efficiency and can result in error. This study investigates the impact of a fully immersive virtual reality (VR) curriculum on training scrub nurses in technical skills and knowledge of performing a complex rTKA, to improve efficiency and reduce error. Method. Ten orthopaedic scrub nurses were recruited and trained in four VR sessions over a 4-week period. Each VR session involved a guided mode, where participants were taught the steps of rTKA surgery by the simulator in a simulated operating theatre. The latter 3 sessions involved a guided mode followed by an unguided VR assessment. Outcome measures in the unguided assessment were related to procedural sequence, duration of surgery and efficiency of movement. Transfer of skills was assessed during a pre-training and post-training assessment, where participants completed multi-step instrument selection and assembly using the real equipment. A pre and post-training questionnaire assessed the participants knowledge, confidence and anxiety. Results. All participants reported orthopaedics as their primary speciality with mean of 6-years experience. 80% reported they are ‘sometimes’ required to scrub for operations in which they do not feel comfortable with the equipment. All participants improved across the 3 unguided sessions reducing their operative time by 47%, assistive prompts by 75%, dominant hand motion by 28% and head motion by 36%. This transferred into the real-world: Participants completed 11.3% of tasks correctly in pre-training compared to 83.5% correct in the timely selection and assembly of rTKA equipment, post-training. All participants reported increased confidence and reduced anxiety after the training. Conclusion. Unfamiliarity with orthopaedic procedures or equipment is common for scrub nurses and can impact surgical performance. VR training improves their understanding, technical skills and efficiency in complex rTKA. These VR-learnt skills translate into the physical environment. This has important implications on how scrub nurses can be trained remotely, asynchronously and safely to perform complex orthopaedic surgery

Background. Surgical simulators allow learner-focussed skills training, in controllable and reproducible environments suitable for assessment. Aim. To research the face validity (extent to which the simulator resembles reality, determined subjectively by subjects), and construct validity, (ability to objectively differentiate between subjects with varying levels of arthroscopic experience) of a virtual reality arthroscopy simulator, to validate its effectiveness as an educational tool. Methods. Using the simulator insightArthroVR®, 37 subjects were required to perform diagnostic knee arthroscopy, palpate anatomical landmarks and complete questionnaires. The simulator recorded objective data to assess proficiency: time to complete tasks, roughness in instrument handling, and path length covered by the arthroscope and palpation probe. Results. The simulator succeeded in proving face validity: 86.4% participants agreed the simulator provided insight into arthroscopy. Training met the expectations of 91.3% and showed improvement in novices in simulated diagnostic arthroscopy in completion time (p-value=0.036), roughness (p-value=0.026), and path length covered by the arthroscope (p-value=0.008). Furthermore, the simulator was able to discriminate between experts, intermediates and novices, proving construct validity: time of completion (p-value=0.009), the path length covered by the arthroscope (p-value=0.02) and the probe (p-value=0.028). Conclusions. Results demonstrate the simulator succeeds in emulating real arthroscopy and can discriminate between subjects according to arthroscopic experience, proving face and construct validity. Further research on transfer of skills to the operating room needs to be done. With surgery constantly modernising and increasing time constraints with the EWTD, training must be efficient and assessable without compromising patient safety. Simulators could allow trainees earlier exposure to procedures, a wider range of pathologies in a compressed period, practice outside the OR, and an acceleration of the learning curve. This study has taken a step forward in validating a VR simulator and thus a step towards the future of simulation becoming an indispensable adjunct to surgical training

We share our experiences in designing a complete simulator prototype and provide the technological basis to determine whether an immersive medical training environment for vertebroplasty is successful. In our study, the following key research contributions were realised: (1) the effective combination of a virtual reality surgical simulator and a computerised mannequin in designing a novel training setup for medical education, and (2) based on a user-study, the quantitative evaluation through surgical workflow and crisis simulation in proving the face validity of our immersive medical training environment. Medical simulation platforms intend to assist and support surgical trainees by enhancing their skills in a virtual environment. This approach to training is consistent with an important paradigm shift in medical education that has occurred over the past decade. Surgical trainees have traditionally learned interventions on patients under the supervision of a senior physician in what is essentially an apprenticeship model. In addition to exposing patients to some risk, this tends to be a slow and inherently subjective process that lacks objective, quantitative assessment of performance. By proposing our immersive medical simulator we offer the first shared experimental platform for education researchers to design, implement, test, and compare vertebroplasty training methods. We collected feedback from two expert and two novice residents, on improving the teaching paradigm during vertebroplasty. In this way, this limits the risks of complications during the skill acquisition phase that all learners must pass through. The complete simulation environment was evaluated on a 5-pt Likert scale format: (1) strongly disagree, (2) disagree, (3) neither agree nor disagree, (4) agree, and (5) strongly agree. When assessing all aspects of the realism of the simulation environment, specifically on whether it is suitable for the training of technical skills team training, the participating surgeons gave an average score of 4.5. Additionally, we also simulated a crisis simulation. During training, the simulation instructor introduced a visualisation depicting cement extravasation into a perivertebral vein. Furthermore, the physiology of the computerised mannequin was influenced by the instructor simulating a lung embolism by gradually lowering the oxygen saturation from 98% to 80% beginning at a standardised point during the procedure. The simulation was stopped after the communication between the surgeon and the anaesthetist occurred which determined their acknowledgment that an adverse event occurred. The realism of this crisis simulation was ranked with an average score of 4.75. To our knowledge this is the first virtual reality simulator with the capacity to control the introduction of adverse events or complication yielding a wide spectrum of highly adjustable crisis simulation scenarios. Our conclusions validate the importance of incorporating surgical workflow analysis together with virtual reality, human multisensory responses, and the inclusion of real surgical instruments when considering the design of a simulation environment for medical education. The proposed training environment for individuals can be certainly extended to training medical teams

The inability to consistently position components is associated with the major complications of hip replacement including instability, wear, liner breakage, limb length discrepancy, and limited function. This was a major catalyst for the demise of hard-on-hard bearings. The greatest challenge is accurate, reproducible positioning of acetabular component which is obtained in a surprisingly low percentage of cases. Other major issues include consistently obtaining proper limb length, offset, component sizing, and complete seating without fracture of either the acetabulum or the femur. There are two approaches to this issue; to either use virtual reality which applies technology that provides surrogates to direct visualization of components. The major issues with computer assisted techniques include questions of accuracy and increased time and cost. The other approach is to utilise intraoperative imaging which has been the gold standard traditionally, however, previously it has been a challenge to utilise intraoperative imaging without adding substantial time and cost. Historically intraoperative imaging has not been adopted because it disrupts work flow, the quality of images has been inadequate, and it has added too much additional time to allow for a series of repeat radiographs to be obtained. Modifications of existing portable imaging that utilise direct radiography (DR plate technology) allow for intraoperative images that display within seconds. Imbedded software allows measurement of all parameters of interest. Three or 4 systems are currently in use, and this is not virtual reality but it is the gold standard. Advantages include higher quality images, faster service speed, minimal impact on OR work flow, eventual reduction in operating costs, elimination of processing of chemicals and film room/storage room, and most importantly the elimination of outliers and return to the operating room due to unexpected findings on recovery room radiographs. Intraoperative imaging has been utilised at a number of centers in recent years and has led to numerous intraoperative changes to optimise component implantation in a surprisingly high percentage of cases. Advances in technology have made intraoperative digital imaging a practical feasible strategy to avoid outliers that increase complications and compromise results. The rapidly evolving technology makes this a very attractive option for optimising total hip component placement. In addition it is an excellent teaching tool that is rapidly embraced by residents and fellows and is an extremely effective in eliminating outliers

Introduction. Junior level orthopaedic surgery residents who train with a virtual surgical simulator can lead to improved arthroscopy performance. Methods. Study participants were first and second year orthopaedic surgery residents at a single institution who were randomized to either train on the virtual reality surgical simulator (Insight Arthro VR) for a total of 2.5 hours (n=8) or receive 2 hours of didactic lectures with models (non-simulator) (n=6). Both groups were then evaluated in both knee and shoulder arthroscopy using a cadaver. Performance was measured by time to completion of a standardized protocol checklist and cartilage-grading index (CGI) (scale 0–10). Results. All subjects had no previous arthroscopy experience prior to the study. The simulator group had a shorter time to completion in both knee (simulator: 5.1 ± 1.8 min, non-simulator: 8.0 ± 4.4 min; p=0.09) and shoulder (simulator: 6.1 ± 1.5 min, non-simulator: 9.9 ± 3.2 min; p=0.02) arthroscopy. Similarly, the simulator group had improved CGI scores in both the knee (simulator: 4.0 ± 1.1, non-simulator: 5.3 ± 1.5; p=0.07) and shoulder (simulator: 3.4 ± 0.8, non-simulator: 5.5 ± 1.6; p=0.008) arthroscopy. Discussion and Conclusion. This study suggests that surgical simulators are beneficial in arthroscopy skills development for orthopaedic surgery residents

Background. Cam-type femoro-acetabular impingement (FAI) is increasingly recognised as a cause of mechanical hip symptoms in young adults. It is likely that it is a cause of early hip degeneration. Ganz et al have developed a therapeutic procedure involving trochanteric flip osteotomy and dislocation of the hip, and have reported good results. We have developed an arthroscopic osteochondroplasty to reshape the proximal femur and relieve impingement. Methods. Fifty patients who presented with mechanical hip symptoms and had demonstrable cam-type FAI on radially-reconstructed MR arthrography, were treated by arthroscopic osteochondroplasty. Ten patients had a post-operative CT; from these images flexion and internal rotation range was tested in a virtual reality (VR) model to determine adequacy of resection. All patients were followed up for a minimum of one year, and post-operative Non-Arthritic Hip Scores (NAHS, maximum possible score 100) compared with pre-operative NAHS. Results. Mean operating time was 110 minutes. 31 patients were discharged on the day of surgery, the remainder on the following day. There were no complications. All patients were asked to be partially weight-bearing with crutches for four weeks but most returned to work within two weeks. The VR models showed satisfactory resection, although there was clear evidence of improved precision with practice. Symptoms improved in all but two patients, with mean NAHS improving from 54 pre-operatively to 87 at one year. The two patients who did not improve, were both found to have unexpectedly extensive acetabular articular cartilage damage. Conclusion. Arthroscopic femoral reshaping to relieve FAI is feasible, safe and reliable. However it is technically difficult and time-consuming. The results are comparable to open dislocation and debridement, but the arthroscopic procedure avoids the prolonged disability and the complications associated with trochanteric flip osteotomy

Remarkable strides made in medical technology and techniques of total knee arthroplasty over past 5 years. These changes have included: minimally invasive surgical techniques, pain management, navigation, kinematic design of prosthesis and recently custom fitted surgical guides based on the anatomic axis. To date, there has been little documentation of the use of these custom-cutting surgical guides. There has been significant controversy as to the necessity of using the neutral alignment of the mechanical axis for this surgery for a long lived replacement. A recent study by Pagnano et al in 2008 demonstrated that it could not be confirmed that improvement in the mechanical axis to zero would lead to a long-term improvement in survivorship, and it was noted that there was actually a slight trend for the outliers to be more successful. A recent study (Three-Dimensional Morphology and Kinematics of the Distal Part of the Femur Viewed in Virtual Reality Eckhoff et al, JBJS 2005) provides kinematic and morphologic validation for a single cylindrical flexion-extension axis of the knee. This fixed flexion-extension axis is best approximated by the axis of cylinders, fit to the circular posterior femoral condyles, and is designated the cylindrical axis of the knee. An innovative surgical technique of total knee arthroplasty has been developed using MRI-based custom fitting cutting blocks. This technique advocates the use of an individual knee MRI, utilizes the cylindrical axis and proceeds with precise measurements of the arthritic knee. Proprietary software creates a 3-dimensional model of the knee and then corrects the deformity virtually, and recreates the knee's pre-arthritic alignment. Guides are designed to fit on diseased bone and set transverse resection and rotation and enable implant placement that restores joint to pre-disease position. 32 patients were enrolled in this IRB-approved study of total knee replacement. Pre-operative standing anterior-posterior lower extremity x-rays were required for assessment of the degree of malalignment. Patients with a malalignment greater than 15 degrees were excluded from the study. Only 26 knees with varus alignment were in the final study group since the valgus group was very small in number. Computer navigation appears to provide the most precise kinematic measurement of the knee, and was used during the operation to assess and quantitate the pre-operative, intra-operative, and post-operative alignment and potential correction. The pre-operative pathologic malalignment was documented by navigation and the post-operative alignment did demonstrate some correction of this malalignment back to the presumed pre-arthritic alignment. Change in alignment of 26 varus knees was documented as the following: Pre-op AP standing XRay: average 6.9 degrees varus; Pre-op Navigation: average 6.3 degrees varus; Post-op Navigation: average 3.4 varus degrees. This resulted in post-operative correction of the varus knee to 2.9 degrees. Documentation of resections planes was noted as the following: Femur AP Resection 3.0 degrees valgus (r: 3.5 varus-4.0 valgus); Femur Distal Resection: 3.7 degrees flexion (r: 2.5 ext-10.0 flex); Femur Rotation Resection: 3.6 degrees internal rotation (r: 2.5 ext-7.5int); Tibia AP Resection 3.3 degrees varus (r: 2.0 valgus-6.0 varus); Tibia Slope Resection: 3.7 degrees posterior (r: 0.5 ant-9.0 post). This study did support the premise that custom-fitting surgical guides locate the cylindrical axis, as determined by Eckhoff et al. This may provide the patient with less soft tissue stress and allowing a quicker return to function as reported in earlier studies. This surgeon did recognize obstacles using the custom-fitting surgical guides including determining the extent of debridement of soft tissue and osteophytes to allow appropriate capture of the blocks, as well as the risk of PCL injury. Navigation can be used as a training tool to aid in the prevention of significant error. By locating the cylindrical axis, the natural kinematics of the knee are addressed, including the soft tissue tension. As the mechanical axis is being challenged, we look to the cylindrical axis as our potential objective, unique for each patient. Further validated studies are required, to understand the operative kinematics and the long term effects of the cylindrical axis

The aim of this study was to investigate the effect of laboratory-based simulator training on the ability of surgical trainees to perform diagnostic arthroscopy of the knee.

A total of 20 junior orthopaedic trainees were randomised to receive either a fixed protocol of arthroscopic simulator training on a bench-top knee simulator or no additional training. Motion analysis was used to assess performance objectively. Each trainee then received traditional instruction and demonstrations of diagnostic arthroscopy of the knee in theatre before performing the procedure under the supervision of a blinded consultant trainer. Their performance was assessed using a procedure-based assessment from the Orthopaedic Competence Assessment Project and a five-point global rating assessment scale.

In theatre the simulator-trained group performed significantly better than the untrained group using the Orthopaedic Competence Assessment Project score (p = 0.0007) and assessment by the global rating scale (p = 0.0011), demonstrating the transfer of psychomotor skills from simulator training to arthroscopy in the operating theatre. This has implications for the planning of future training curricula.