Does virtual reality simulation have a role in training trauma and orthopaedic surgeons?

AIMS: The aim of this study was to assess the current evidence relating to the benefits of virtual reality (VR) simulation in orthopaedic surgical training, and to identify areas of future research. MATERIALS AND METHODS: A literature search using the MEDLINE, Embase, and Google Scholar databases was performed. The results' titles, abstracts, and references were examined for relevance. RESULTS: A total of 31 articles published between 2004 and 2016 and relating to the objective validity and efficacy of specific virtual reality orthopaedic surgical simulators were identified. We found 18 studies demonstrating the construct validity of 16 different orthopaedic virtual reality simulators by comparing expert and novice performance. Eight studies have demonstrated skill acquisition on a simulator by showing improvements in performance with repeated use. A further five studies have demonstrated measurable improvements in operating theatre performance following a period of virtual reality simulator training. CONCLUSION: The demonstration of 'real-world' benefits from the use of VR simulation in knee and shoulder arthroscopy is promising. However, evidence supporting its utility in other forms of orthopaedic surgery is lacking. Further studies of validity and utility should be combined with robust analyses of the cost efficiency of validated simulators to justify the financial investment required for their use in orthopaedic training. Cite this article: Bone Joint J 2018;100-B:559-65

A haptic training environment for the heart myoblast cell injection procedure

The heart muscle of a cardiac arrest victim continues to accumulate damage throughout its lifetime. This reduces the heart\u27s ability to pump sufficient oxygen and nutrient blood to meet the body\u27s needs. Medical researchers have shown that direct injection of pre-harvested skeletal myoblast cells into the heart can restore some muscle function [1]. This operative procedure usually necessitates the surgeon to open a patient\u27s chest. The open chest procedure is usually a lengthy process and often extends the recovery time of the patient. Alternatively, a high accuracy surgical aid robotic system can be used to assist the thoracoscopic surgery [2][3]. While the robotic surgical method aids faster patient recovery, a less experienced surgeon can potentially cause damage to surrounding tissue. This paper presents a study into the development of a virtual haptically-enabled heart myoblast injection simulation environment, which can be used to train new surgeons to get hands on experience with the process. The paper also discusses the development of a generic constraint motion technique for needle insertion. Experiments on human performance measures and efficacy, while interacting with haptic feedback training models, are also presented. The experiment involved 10 operators, with each person repeating the needle insertion and injection 10 times. A notable improvement in the task execution time with the number of repetitions was observed. Operators improved their time by up to 300% compared to their first training attempt for a static heart scenario. Under a dynamic heart motion, operator\u27s performance was slightly lower, with the successful rate of completing the experiment reduced from 84% to 75%

Virtual haptic cell model for operator training

Microrobotic cell injection is an area of growing research interest. Typically, operators rely on visual feedback to perceive the microscale environment and are subject to lengthy training times and low success rates. Haptic interaction offers the ability to utilise the operator’s haptic modality and to enhance operator performance. Our earlier work presented a haptically enabled system for assisting the operator with certain aspects of the cell injection task. The system aimed to enhance the operator’s controllability of the micropipette through a logical mapping between the haptic device and microrobot, as well as introducing virtual fixtures for haptic guidance. The system was also designed in such a way that given the availability of appropriate force sensors, haptic display of the cell penetration force is straightforward. This work presents our progress towards a virtual replication of the system, aimed at facilitating offline operator training. It is suggested that operators can use the virtual system to train offline and later transfer their skills to the physical system. In order to achieve the necessary representation of the cell within the virtual system, methods based on a particle-based cell model are utilised. In addition to providing the necessary visual representation, the cell model provides the ability to estimate cell penetration forces and haptically display them to the operator. Two different approaches to achieving the virtual system are discussed

High fidelity simulation of the endoscopic transsphenoidal approach: Validation of the UpSurgeOn TNS Box

Objective: Endoscopic endonasal transsphenoidal surgery is an established technique for the resection of sellar and suprasellar lesions. The approach is technically challenging and has a steep learning curve. Simulation is a growing training tool, allowing the acquisition of technical skills pre-clinically and potentially resulting in a shorter clinical learning curve. We sought validation of the UpSurgeOn Transsphenoidal (TNS) Box for the endoscopic endonasal transsphenoidal approach to the pituitary fossa./ Methods: Novice, intermediate and expert neurosurgeons were recruited from multiple centres. Participants were asked to perform a sphenoidotomy using the TNS model. Face and content validity were evaluated using a post-task questionnaire. Construct validity was assessed through post-hoc blinded scoring of operative videos using a Modified Objective Structured Assessment of Technical Skills (mOSAT) and a Task-Specific Technical Skill scoring system./ Results: Fifteen participants were recruited of which n = 10 (66.6%) were novices and n = 5 (33.3%) were intermediate and expert neurosurgeons. Three intermediate and experts (60%) agreed that the model was realistic. All intermediate and experts (n = 5) strongly agreed or agreed that the TNS model was useful for teaching the endonasal transsphenoidal approach to the pituitary fossa. The consensus-derived mOSAT score was 16/30 (IQR 14–16.75) for novices and 29/30 (IQR 27–29) for intermediate and experts (p < 0.001, Mann–Whitney U). The median Task-Specific Technical Skill score was 10/20 (IQR 8.25–13) for novices and 18/20 (IQR 17.75–19) for intermediate and experts (p < 0.001, Mann-Whitney U). Interrater reliability was 0.949 (CI 0.983–0.853) for OSATS and 0.945 (CI 0.981–0.842) for Task-Specific Technical Skills. Suggested improvements for the model included the addition of neuro-vascular anatomy and arachnoid mater to simulate bleeding vessels and CSF leak, respectively, as well as improvement in materials to reproduce the consistency closer to that of human tissue and bone./ Conclusion: The TNS Box simulation model has demonstrated face, content, and construct validity as a simulator for the endoscopic endonasal transsphenoidal approach. With the steep learning curve associated with endoscopic approaches, this simulation model has the potential as a valuable training tool in neurosurgery with further improvements including advancing simulation materials, dynamic models (e.g., with blood flow) and synergy with complementary technologies (e.g., artificial intelligence and augmented reality)

Validity of a Novel Digitally Enhanced Skills Training Station for Freehand Distal Interlocking.

Background and Objectives: Freehand distal interlocking of intramedullary nails is technically demanding and prone to handling issues. It requires precise placement of a screw through the nail under fluoroscopy guidance and can result in a time consuming and radiation expensive procedure. Dedicated training could help overcome these problems. The aim of this study was to assess construct and face validity of new Digitally Enhanced Hands-On Surgical Training (DEHST) concept and device for training of distal interlocking of intramedullary nails. Materials and Methods: Twenty-nine novices and twenty-four expert surgeons performed interlocking on a DEHST device. Construct validity was evaluated by comparing captured performance metrics-number of X-rays, nail hole roundness, drill tip position and drill hole accuracy-between experts and novices. Face validity was evaluated with a questionnaire concerning training potential and quality of simulated reality using a 7-point Likert scale. Results: Face validity: mean realism of the training device was rated 6.3 (range 4-7). Training potential and need for distal interlocking training were both rated with a mean of 6.5 (range 5-7), with no significant differences between experts and novices, p ≥ 0.234. All participants (100%) stated that the device is useful for procedural training of distal nail interlocking, 96% wanted to have it at their institution and 98% would recommend it to colleagues. Construct validity: total number of X-rays was significantly higher for novices (20.9 ± 6.4 versus 15.5 ± 5.3, p = 0.003). Success rate (ratio of hit and miss attempts) was significantly higher for experts (novices hit: n = 15; 55.6%; experts hit: n = 19; 83%, p = 0.040). Conclusion: The evaluated training device for distal interlocking of intramedullary nails yielded high scores in terms of training capability and realism. Furthermore, construct validity was proven by reliably discriminating between experts and novices. Participants indicate high further training potential as the device may be easily adapted to other surgical tasks

Virtual and Augmented Reality in Medical Education

Virtual reality (VR) and augmented reality (AR) are two contemporary simulation models that are currently upgrading medical education. VR provides a 3D and dynamic view of structures and the ability of the user to interact with them. The recent technological advances in haptics, display systems, and motion detection allow the user to have a realistic and interactive experience, enabling VR to be ideal for training in hands-on procedures. Consequently, surgical and other interventional procedures are the main fields of application of VR. AR provides the ability of projecting virtual information and structures over physical objects, thus enhancing or altering the real environment. The integration of AR applications in the understanding of anatomical structures and physiological mechanisms seems to be beneficial. Studies have tried to demonstrate the validity and educational effect of many VR and AR applications, in many different areas, employed via various hardware platforms. Some of them even propose a curriculum that integrates these methods. This chapter provides a brief history of VR and AR in medicine, as well as the principles and standards of their function. Finally, the studies that show the effect of the implementation of these methods in different fields of medical training are summarized and presented

Patterns in Bone Drilling Performance Before and After the 2017 Motors Skills Course of the Southwest Orthopaedic Trauma Association

Background: Although experience within the operating room can help surgeons learn simple bone-drilling techniques, outside training may be better suited for complex procedures. We adapted a rotary handpiece to evaluate bone drilling skills of orthopaedic resident physicians during the 2017 motor skills course of the Southwest Orthopaedic Trauma Association (SWOTA). Methods: A total of 25 postgraduate year-one orthopaedic residents from seven institutions were asked to perform a bicortical drilling task three times before and after attending a motor skills course. Kinetic and kinematic data were collected using force, acceleration, and visual sensors. Results: A total of 16 parameters were measured. Variables statistically significant after the course were as follows: over-penetration (28.8-18.2 mm), skiving (22%-6%), preparation time (27.3-9.65 seconds), drilling time (8.28-9.35 seconds), palmar-dorsal vibration (1.76- 2.05 m/s2), maximum drilling force (58.56-84.30 N), and maximum revolution per minute (RPM; 917-944). The interdependence of these parameters taken separately for pre- and post-course performance are presented. Notable correlations include: over-penetration with force (0.65), palmar-dorsal toggle (0.65), vibration in palmar-dorsal (0.53), time (-0.41), and RPM (-0.36); time with both RPM (0.38) and palmar-dorsal toggle (-0.40); and force with both RPM (-0.41) and palmardorsal toggle (0.32). Conclusions: The correlation data presented provide insight into patterns between measured parameters regarding where performance metrics are and are not coupled. Evidence for motor skill acquisition across both short- and long-time scales are elucidated

Validating Metrics for a Mastoidectomy Simulator

Abstract. One of the primary barriers to the acceptance of surgical simulators is that most simulators still require a significant amount of an instructing surgeon&apos;s time to evaluate and provide feedback to the students using them. Thus, an important area of research in this field is the development of metrics that can enable a simulator to be an essentially self-contained teaching tool, capable of identifying and explaining the user&apos;s weaknesses. However, it is essential that these metrics be validated in able to ensure that the evaluations provided by the &quot;virtual instructor&quot; match those that the real instructor would provide were he/she present. We have previously proposed a number of algorithms for providing automated feedback in the context of a mastoidectomy simulator. In this paper, we present the results of a user study in which we attempted to establish construct validity (with inter-rater reliability) for our simulator itself and to validate our metrics. Fifteen subjects (8 experts, 7 novices) were asked to perform two virtual mastoidectomies. Each virtual procedure was recorded, and two experienced instructing surgeons assigned global scores that were correlated with subjects&apos; experience levels. We then validated our metrics by correlating the scores generated by our algorithms with the instructors&apos; global ratings, as well as with metric-specific sub-scores assigned by one of the instructors

Filling the gap between the OR and virtual simulation : a European study on a basic neurosurgical procedure

Aki Laakso tutkimusryhmän jäsenenä.Currently available simulators are supposed to allow young neurosurgeons to hone their technical skills in a safe environment, without causing any unnecessary harm to their patients caused by their inexperience. For this training method to be largely accepted in neurosurgery, it is necessary to prove simulation efficacy by means of large-scale clinical validation studies. We correlated and analysed the performance at a simulator and the actual operative skills of different neurosurgeons (construct validity). We conducted a study involving 92 residents and attending neurosurgeons from different European Centres; each participant had to perform a virtual task, namely the placement of an external ventricular drain (EVD) at a neurosurgical simulator (ImmersiveTouch). The number of attempts needed to reach the ventricles and the accuracy in positioning the catheter were assessed. Data suggests a positive correlation between subjects who placed more EVDs in the previous year and those who get better scores at the simulator (p = .008) (fewer attempts and better surgical accuracy). The number of attempts to reach the ventricle was also analysed; senior residents needed fewer attempts (mean = 2.26; SD = 1.11) than junior residents (mean = 3.12; SD = 1.05) (p = .007) and staff neurosurgeons (mean = 2.89, SD = 1.23). Scoring results were compared by using the Fisher's test, for the analysis of the variances, and the Student's T test. Surprisingly, having a wider surgical experience overall does not correlate with the best performance at the simulator. The performance of an EVD placement on a simulator correlates with the density of the neurosurgical experience for that specific task performed in the OR, suggesting that simulators are able to differentiate neurosurgeons according to their surgical ability. Namely this suggests that the simulation performance reflects the surgeons' consistency in placing EVDs in the last year.Peer reviewe

Learning force patterns with a multimodal system using contextual cues

Previous studies on learning force patterns (fine motor skills) have focused on providing “punctual information”, which means users only receive information about their performance at the current time step. This work proposes a new approach based on “contextual information”, in which users receive information not only about the current time step, but also about the past (how the target force has changed over time) and the future (how the target force will change). A test was run to compare the performance of the contextual approach in relation to the punctual information, in which each participant had to memorize and then reproduce a pattern of force after training with a multimodal system. The findings suggest that the contextual approach is a useful strategy for force pattern learning. The advantage of the contextual information approach over the punctual information approach is that users receive information about the evolution of their performance (helping to correct the errors), and they also receive information about the next forces to be exerted (providing them with a better understanding of the target force profile). Finally, the contextual approach could be implemented in medical training platforms or surgical robots to extend the capabilities of these systems