A Review of Virtual Reality Based Training Simulators for Orthopaedic Surgery

This review presents current virtual reality based training simulators for hip, knee and other orthopaedic surgery, including elective and trauma surgical procedures. There have not been any reviews focussing on hip and knee orthopaedic simulators. A comparison of existing simulator features is provided to identify what is missing and what is required to improve upon current simulators. In total 11 total hip replacement pre-operative planning tools were analysed, plus 9 hip trauma fracture training simulators. Additionally 9 knee arthroscopy simulators and 8 other orthopaedic simulators were included for comparison. The findings are that for orthopaedic surgery simulators in general, there is increasing use of patient-specific virtual models which reduce the learning curve. Modelling is also being used for patient-specific implant design and manufacture. Simulators are being increasingly validated for assessment as well as training. There are very few training simulators available for hip replacement, yet more advanced virtual reality is being used for other procedures such as hip trauma and drilling. Training simulators for hip replacement and orthopaedic surgery in general lag behind other surgical procedures for which virtual reality has become more common. Further developments are required to bring hip replacement training simulation up to date with other procedures. This suggests there is a gap in the market for a new high fidelity hip replacement and resurfacing training simulator

A review of virtual reality based training simulators for orthopaedic surgery

This is the author accepted manuscript. The final version is available from Elsevier via the DOI in this recordThis review presents current virtual reality based training simulators for hip, knee and other orthopaedic surgery, including elective and trauma surgical procedures. There have not been any reviews focussing on hip and knee orthopaedic simulators. A comparison of existing simulator features is provided to identify what is missing and what is required to improve upon current simulators. In total 11 hip replacements pre-operative planning tools were analysed, plus 9 hip trauma fracture training simulators. Additionally 9 knee arthroscopy simulators and 8 other orthopaedic simulators were included for comparison. The findings are that for orthopaedic surgery simulators in general, there is increasing use of patient-specific virtual models which reduce the learning curve. Modelling is also being used for patient-specific implant design and manufacture. Simulators are being increasingly validated for assessment as well as training. There are very few training simulators available for hip replacement, yet more advanced virtual reality is being used for other procedures such as hip trauma and drilling. Training simulators for hip replacement and orthopaedic surgery in general lag behind other surgical procedures for which virtual reality has become more common. Further developments are required to bring hip replacement training simulation up to date with other procedures. This suggests there is a gap in the market for a new high fidelity hip replacement and resurfacing training simulator.Wessex Academic Health Science Network (Wessex AHSN) Innovation and Wealth Creation Accelerator Fund 2014/15Bournemouth Universit

A review of the evolution of robotic-assisted total hip arthroplasty.

INTRODUCTION: Total hip arthroplasty (THA) is currently a very successful operation but continues to evolve as we try to perfect techniques and improve outcomes for our patients. Robotic hip surgery (RHS) began with the 'active' ROBODOC system in the 1980s. There were drawbacks associated with the original ROBODOC and most recently, the MAKO robot was introduced with early promising results. AIM: The aim of this paper is to provide an up-to-date review surrounding this area and discuss the pros and cons of this technique. METHODS: A literature review searching Medline, Embase, Ovidsp, Cochrane library, pubmed database and google scholar was performed searching keywords including: 'Robotic hip surgery', 'Robotic orthopaedic surgery', 'Computer assisted hip surgery', 'robotic arthroplasty', and 'computer assisted orthopaedic surgery'. CONCLUSION: Robotic hip surgery aims to tackle the limitations of the human factor in surgery by promising reproducible and reliable methods of component positioning in arthroplasty surgery. However, as orthopaedic surgeons, we must critically appraise all new technology and support the use providing there is sound robust evidence backing it

Virtual Hip Replacement Simulator For 3D Printed Implants.

This research presents a virtual reality simulator for total hip replacement surgery. The simulator supports a library of 3D hip stem models for different sizes and manufacturers. The 3D hip stems can be adjusted in size and shape by parametric software and sent for 3D printing. Biocompatible materials such as titanium enable the 3D printed stems to be directly implanted on patients. Currently surgical simulation for orthopaedic procedures is not as advanced as other surgical disciplines. As a result there are only limited training simulators available for orthopaedic surgery such as total hip replacement, hip resurfacing or knee replacement. This is demanding since 66,000 hip replacements are performed annually in the UK. One area which is neglected in VR orthopaedic simulation is the digital library generation of implants. Currently orthopaedic surgeons have limited choice in terms of an exact identification of implant specific to patient requirements. We conducted a literature review of orthopaedic training simulators which found no simulators catering for this

Characterization of a Contact-Stylus Surface Digitization Method Using Collaborative Robots: Accuracy Evaluation in the Context of Shoulder Replacement or Resurfacing

Total shoulder arthroplasty (TSA) is the third most common joint replacement. While robot-assisted hip and knee replacement technologies have enjoyed extensive development, this has been limited in the upper limb. This work focused on quantifying the localization accuracy of a robotic system, and evaluating its efficacy in the context of TSA. A collaborative robot was fitted with a stylus tip to perform manual surface digitizations using the robot’s encoder output. In the first experiment, two precision-machined master cubes, representing the working volume around a glenoid structure, were used for system validation. Next, cadaveric glenoids were digitized and compared to a ‘gold standard’ laser scanner. Digitization errors were 0.37±0.27 mm, showing that collaborative robotics can be used for osseous anatomy digitization. This thesis presents two novel concepts: 1) use of collaborative robotics for manually operated surface digitizing, and 2) optical fiducial technique, allowing registration between a laser scanner and stylus digitizer

Robot ontologies for sensor- and Image-guided surgery

Robots and robotics are becoming more com- plex and flexible, due to technological advancement, improved sensing capabilities and machine intelligence. Service robots target a wide range of applications, relying on advanced Human–Robot Interaction. Medical robotics is becoming a leading application area within, and the number of surgical, rehabilitation and hospital assistance robots is rising rapidly. However, the complexity of the medical environment has been a major barrier, preventing a wider use of robotic technology, thus mostly teleoperated, human-in-the-loop control solutions emerged so far. Providing smarter and better medical robots requires a systematic approach in describing and translating human processes for the robots. It is believed that ontologies can bridge human cognitive understanding and robotic reasoning (machine intelligence). Besides, ontologies serve as a tool and method to assess the added value robotic technology brings into the medical environment. The purpose of this paper is to identify relevant ontology research in medical robotics, and to review the state-of-the art. It focuses on the surgical domain, fundamental terminology and interactions are described for two example applications in neurosurgery and orthopaedics

Machine learning and interactive real-time simulation for training on relevant total hip replacement skills.

Virtual Reality simulators have proven to be an excellent tool in the medical sector to help trainees mastering surgical abilities by providing them with unlimited training opportunities. Total Hip Replacement (THR) is a procedure that can benefit significantly from VR/AR training, given its non-reversible nature. From all the different steps required while performing a THR, doctors agree that a correct fitting of the acetabular component of the implant has the highest relevance to ensure successful outcomes. Acetabular reaming is the step during which the acetabulum is resurfaced and prepared to receive the acetabular implant. The success of this step is directly related to the success of fitting the acetabular component. Therefore, this thesis will focus on developing digital tools that can be used to assist the training of acetabular reaming. Devices such as navigation systems and robotic arms have proven to improve the final accuracy of the procedure. However, surgeons must learn to adapt their instrument movements to be recognised by infrared cameras. When surgeons are initially introduced to these systems, surgical times can be extended up to 20 minutes, maximising surgical risks. Training opportunities are sparse, given the high investment required to purchase these devices. As a cheaper alternative, we developed an Augmented Reality (AR) alternative for training on the calibration of imageless navigation systems (INS). At the time, there were no alternative simulators that using head-mounted displays to train users into the steps to calibrate such systems. Our simulator replicates the presence of an infrared camera and its interaction with the reflecting markers located on the surgical tools. A group of 6 hip surgeons were invited to test the simulator. All of them expressed their satisfaction with the ease of use and attractiveness of the simulator as well as the similarity of interaction with the real procedure. The study confirmed that our simulator represents a cheaper and faster option to train multiple surgeons simultaneously in the use of Imageless Navigation Systems (INS) than learning exclusively on the surgical theatre. Current reviews on simulators for orthopaedic surgical procedures lack objective metrics of assessment given a standard set of design requirements. Instead, most of them rely exclusively on the level of interaction and functionality provided. We propose a comparative assessment rubric based on three different evaluation criteria. Namely immersion, interaction fidelity, and applied learning theories. After our assessment, we found that none of the simulators available for THR provides an accurate interactive representation of resurfacing procedures such as acetabular reaming based on force inputs exerted by the user. This feature is indispensable for an orthopaedics simulator, given that hand-eye coordination skills are essential skills to be trained before performing non-reversible bone removal on real patients. Based on the findings of our comparative assessment, we decided to develop a model to simulate the physically-based deformation expected during traditional acetabular reaming, given the user’s interaction with a volumetric mesh. Current interactive deformation methods on high-resolution meshes are based on geometrical collision detection and do not consider the contribution of the materials’ physical properties. By ignoring the effect of the material mechanics and the force exerted by the user, they become inadequate for training on hand- eye coordination skills transferable to the surgical theatre. Volumetric meshes are preferred in surgical simulation to geometric ones, given that they are able to represent the internal evolution of deformable solids resulting from cutting and shearing operations. Existing numerical methods for representing linear and corotational FEM cuts can only maintain interactive framerates at a low resolution of the mesh. Therefore, we decided to train a machine-learning model to learn the continuum mechanic laws relevant to acetabular reaming and predict deformations at interactive framerates. To the best of our knowledge, no research has been done previously on training a machine learning model on non-elastic FEM data to achieve results at interactive framerates. As training data, we used the results from XFEM simulations precomputed over 5000 frames for plastic deformations on tetrahedral meshes with 20406 elements each. We selected XFEM simulation as the physically-based deformation ground-truth given its accuracy and fast convergence to represent cuts, discontinuities and large strain rates. Our machine learning-based interactive model was trained following the Graph Neural Networks (GNN) blocks. GNNs were selected to learn on tetrahedral meshes as other supervised-learning architectures like the Multilayer perceptron (MLP), and Convolutional neural networks (CNN) are unable to learn the relationships between entities with an arbitrary number of neighbours. The learned simulator identifies the elements to be removed on each frame and describes the accumulated stress evolution in the whole machined piece. Using data generated from the results of XFEM allowed us to embed the effects of non-linearities in our interactive simulations without extra processing time. The trained model executed the prediction task using our tetrahedral mesh and unseen reamer orientations faster per frame than the time required to generate the training FEM dataset. Given an unseen orientation of the reamer, the trained GN model updates the value of accumulated stress on each of the 20406 tetrahedral elements that constitute our mesh during the prediction task. Once this value is updated, the tetrahedrons to be removed from the mesh are identified using a threshold condition. After using each single-frame output as input for the following prediction repeatedly for up to 60 iterations, our model can maintain an accuracy of up to 90.8% in identifying the status of each element given their value of accumulated stress. Finally, we demonstrate how the developed estimator can be easily connected to any game engine and included in developing a fully functional hip arthroplasty simulator

WebGL-Based Simulation of Bone Removal in Surgical Orthopeadic Procedures

The effective role of virtual reality simulators in surgical operations has been demonstrated during the last decades. The proposed work has been done to give a perspective of the actual orthopeadic surgeries such as a total shoulder arthroplasty with low incidence and visibility of the operation to the surgeon. The research in this thesis is focused on the design and implementation of a web-based graphical feedback for a total shoulder arthroplasty (TSA) surgery. For portability of the simulation and powerful 3D programming features, WebGL is being applied. To simulate the reaming process of the shoulder bone, multiple steps has been passed to be able to remove the volumetric amount of bone which was touched by the reamer tool. A fast and accurate collision detection algorithm utilizing Möller –Trumbore ray-triangle method was implemented to detect the first collision of the bone and the tool in order to accelerate the computations for the bone removal process. Once the collision detected, a mesh Boolean operation using CSG method is being invoked to calculate the volumetric amount of bone which is intersected with the tool and should be removed. This work involves the user interaction to transform the tool in a Three.js scene for the simulated operation

Virtual Hip Replacement Simulator For 3D Printed Implants

Proceedings of the 2017 Design of Medical Devices Conference, DMD2017 April 10-13, 2017, Minneapolis, Minnesota, USAWessex Academic Health Science Network (WAHSN

Experimental Analysis of Parameters Influencing the Bone Burring Process

The experimental quantification of the bone removal characteristics associated with bone burring represents a desirable outcome mainly for the selection of optimal parameters. An experimental apparatus was developed that allowed for concurrent measurement of three outputs associated with the bone removal process (cutting force, vibration, and temperature) as a function of various burring-specific parameters. Initial process trends were established on a uniform sawbone analog through use of a fully balanced multivariate statistical analysis. A smaller set of optimal and suboptimal parameters were further validated using a porcine femur. From the parameters tested, an optimal tool configuration, to avoid high temperature and high vibration, was found to be a 6 mm sphere burr at a rotational speed of 15,000 rpm, feed rate of 2 mm/s and a path overlap of 50%. This set of parameters also provided flexibility in tool depth/orientation angle relative to the bone without sacrificing optimal process outcomes