Effectiveness of Virtual Reality Training in Orthopaedic Surgery

Validation of a novel, low-fidelity virtual reality simulator and an artificial intelligence assessment approach for peg transfer laparoscopic training

Simulators are widely used in medical education, but objective and automatic assessment is not feasible with low-fidelity simulators, which can be solved with artificial intelligence (AI) and virtual reality (VR) solutions. The effectiveness of a custom-made VR simulator and an AI-based evaluator of a laparoscopic peg transfer exercise was investigated. Sixty medical students were involved in a single-blinded randomised controlled study to compare the VR simulator with the traditional box trainer. A total of 240 peg transfer exercises from the Fundamentals of Laparoscopic Surgery programme were analysed. The experts and AI-based software used the same criteria for evaluation. The algorithm detected pitfalls and measured exercise duration. Skill improvement showed no significant difference between the VR and control groups. The AI-based evaluator exhibited 95% agreement with the manual assessment. The average difference between the exercise durations measured by the two evaluation methods was 2.61 s. The duration of the algorithmic assessment was 59.47 s faster than the manual assessment. The VR simulator was an effective alternative practice compared with the training box simulator. The AI-based evaluation produced similar results compared with the manual assessment, and it could significantly reduce the evaluation time. AI and VR could improve the effectiveness of basic laparoscopic training.

Movement-based cognitive training does not significantly shorten the learning curve for acquiring arthroscopic basic skills

PURPOSE

Skilful arthroscopy requires an aboveaverage level of manual dexterity. It is evident that particular motor skills can be learned and trained before arthroscopic training. The aim of this prospective cohort study was to investigate the impact of movement-related cognitive training on the learning curve during arthroscopic basic training.

METHODS

Fifty right-handed participants without arthroscopic experience were matched to an intervention group (n = 25) and a control group (n = 25). Prior to basic arthroscopic skill training with a simulator, the intervention group underwent 12 weeks of movement-related cognitive training. Cognitive and motor skills were assessed in both groups by using standardised tests (CogniFit test, angle reproduction test, two-arm coordination test) as a pretest and, for the intervention group, again before arthroscopic training as a posttest. For arthroscopic simulator training, three tasks ('Telescoping', 'Periscoping', 'Triangulation') from the Fundamentals of Arthroscopic Surgery Training module were selected and practiced 10 times with the camera in the right and left hands. The learning progress was quantified by exercise time, camera path length and hook path length.

RESULTS

No significant differences in sex distribution, age distribution or the results of the pretests between the intervention group (n = 21) and the control group (n = 25) were found (n.s.). The intervention group improved significantly from the pretest to the posttest in the CogniFit (p = 0.003) and two-arm coordination test in terms of time (p < 0.001) and errors (p = 0.002) but not in the angle reproduction test. No significant differences were found between the groups for the three arthroscopic tasks.

CONCLUSION

The hypothesis that movement-related cognitive training shortens the learning curve for acquiring arthroscopic basic skills cannot be confirmed. Other factors influencing the learning curve such as talent, teaching method and motivation have a greater impact on the acquisition of complex motor skills.

LEVEL OF EVIDENCE

Level II.

The influence of virtual reality simulation on surgical residents' heart rate during an assessment of arthroscopic technical skills: A prospective, paired observational study

HYPOTHESIS

To demonstrate that a virtual reality (VR) simulation training program reduces heart rate variability during an assessment of surgical trainees' technical skills in arthroscopy.

STUDY DESIGN

Prospective observational matched study.

MATERIALS & METHODS

Thirty-six orthopaedic surgery residents, new to arthroscopy, received standard training in arthroscopic knee surgery, supplemented by additional monthly training for 6months on a VR simulator for 16 of them. At inclusion, the 2 groups (VR and NON-VR) answered a questionnaire and performed a meniscectomy on a VR simulator. After 6months of training, two independent trainers blinded to the inclusion arms evaluated the technical skills of the two groups during meniscectomies on a model and on an anatomical subject. Heart rate variability (HRV) was measured using a wireless heart rate monitor during baseline, VR training, and assessment.

RESULTS

After removing incomplete data, the analysis focused on 10 VR residents matched at inclusion with 10 NON-VR residents. The VR group had a significantly lower heart rate at the final assessment (p=0.02) and lower overall HRV (p=0.05). The low/high frequency ratio (LF/HF) was not significantly different between the groups (1.84 vs 2.05, p=0.66) but the before-after training comparison showed a greater decrease in this ratio in the VR group compared to the NON-VR group -0.76 (-41%) vs -0.08 (-4%).

CONCLUSION

This study demonstrates a significant difference in heart rate variability between trained residents versus untrained residents during the final assessment of their technical skills at 6months. It appears that improving stress management should be an integral part of training programs in arthroscopic surgery.

CLINICAL INTEREST

VR simulators in arthroscopy could improve non-technical skills such as heart rate variability, from the perspective of accountability.

LEVEL OF EVIDENCE

III.

The next generation of healthcare ecosystem in the metaverse

The Metaverse has gained wide attention for being the application interface for the next generation of Internet. The potential of the Metaverse is growing, as Web 3·0 development and adoption continues to advance medicine and healthcare. We define the next generation of interoperable healthcare ecosystem in the Metaverse. We examine the existing literature regarding the Metaverse, explain the technology framework to deliver an immersive experience, along with a technical comparison of legacy and novel Metaverse platforms that are publicly released and in active use. The potential applications of different features of the Metaverse, including avatar-based meetings, immersive simulations, and social interactions are examined with different roles from patients to healthcare providers and healthcare organizations. Present challenges in the development of the Metaverse healthcare ecosystem are discussed, along with potential solutions including capabilities requiring technological innovation, use cases requiring regulatory supervision, and sound governance. This proposed concept and framework of the Metaverse could potentially redefine the traditional healthcare system and enhance digital transformation in healthcare. Similar to AI technology at the beginning of this decade, real-world development and implementation of these capabilities are relatively nascent. Further pragmatic research is needed for the development of an interoperable healthcare ecosystem in the Metaverse.

Immersive virtual reality in orthopedic surgery as elective subject for medical students : First experiences in curricular teaching

BACKGROUND

Virtual reality (VR) simulators have been introduced for skills training in various medical disciplines to create an approximately realistic environment without the risk of patient harm and have improved to more immersive VR (iVR) simulators at affordable costs. There is evidence that training on VR simulators improves technical skills but its use in orthopedic training programs and especially in curricular teaching sessions for medical students are currently not well established. The aim of this study was to describe the implementation of a VR operating theater as an elective course for undergraduate medical students and to evaluate its effect on student learning.

METHODS

An elective course for 12 students was implemented during the summer semester of 2023. Using Oculus Quest 2 headsets (Reality Labs, Meta Platforms, USA) and controllers and the PrecisionOS platform, they were able to train five different surgical procedures. The courses were accompanied by weekly topic discussions and instructional videos. Students were assigned to two groups: group VR vs. group non-VR. The groups were switched after 5 weeks. User feedback and performance development (theoretical and procedural surgical knowledge) after VR training were assessed using three questionnaires.

RESULTS

The students highly appreciated the implementation of VR training into their curriculum and 91% stated that they would opt for further VR training. All students stated that VR training improved their understanding of surgical procedures and that it should be obligatory in surgical training for undergraduate medical students. After 5 weeks of training, students in the VR group achieved significantly better results (100 out of maximum 180 points) than the non-VR group (70 points, p = 0.0495) in procedural surgical knowledge. After completion of the VR training the VR group achieved 106 points and the non-VR group 104 points (p = 0.8564). The procedural knowledge for non-VR group after 5 weeks significantly improved after VR training from 70 to 106 points (p = 0.0087).

CONCLUSION

The iVR can be easily integrated into the curriculum of medical students and is highly appreciated by the participants. The iVR statistically improves the procedural knowledge of surgical steps compared to conventional teaching methods. Further implementation of iVR training in curricular teaching of medical students should be considered.

Hip Arthroscopy Simulator Training With Immersive Virtual Reality Has Similar Effectiveness to Nonimmersive Virtual Reality

PURPOSE

To (1) compare the efficacy of immersive virtual reality (iVR) to nonimmersive virtual reality (non-iVR) training in hip arthroscopy on procedural and knowledge-based skills acquisition and (2) evaluate the relative cost of each platform.

METHODS

Fourteen orthopaedic surgery residents were randomized to simulation training utilizing an iVR Hip Arthroscopy Simulator (n = 7; PrecisionOS) or non-iVR simulator (n = 7; ArthroS Hip VR; VirtaMed). After training, performance was assessed on a cadaver by 4 expert hip arthroscopists through arthroscopic video review of a diagnostic hip arthroscopy. Performance was assessed using the Objective Structured Assessment of Technical Skills (OSATS) and Arthroscopic Surgery Skill Evaluation Tool (ASSET) scores. A cost analysis was performed using the transfer effectiveness ratio (TER) and a direct cost comparison of iVR to non-iVR.

RESULTS

Demographic characteristics did not differ between treatment arms or by training level, hip arthroscopy experience, or prior simulator use. No significant differences were observed in OSATS and ASSET scores between iVR and non-iVR cohorts (OSATS: iVR 19.6 ± 4.4, non-iVR 21.0 ± 4.1, P = .55; ASSET: iVR 23.7 ± 4.5, non-iVR 25.8 ± 4.8, P = .43). The absolute TER was 0.06 and there was a 132-fold cost difference of iVR to non-iVR.

CONCLUSIONS

Hip arthroscopy simulator training with iVR had similar performance results to non-iVR for technical skill and procedural knowledge acquisition after expert arthroscopic video assessment. The iVR platform had similar effectiveness in transfer of skill compared to non-iVR with a 132 times cost differential. CLINICAL RELEVANCE: Due to the accessibility, effectiveness, and relative affordability, iVR training may be beneficial in the future of safe arthroscopic hip training.

The bibliometric analysis of extended reality in surgical training: Global and Chinese perspective

Objectives

The prospect of extended reality (XR) being integrated with surgical training curriculum has attracted scholars. However, there is a lack of bibliometric analysis to help them better understand this field. Our aim is to analyze relevant literature focusing on development trajectory and research directions since the 21st century to provide valuable insights.

Methods

Papers were retrieved from the Web of Science Core Collection. Microsoft Excel, VOSviewer, and CiteSpace were used for bibliometric analysis.

Results

Of the 3337 papers published worldwide, China contributed 204, ranking fifth. The world's enthusiasm for this field has been growing since 2000, whereas China has been gradually entering since 2001. Although China had a late start, its growth has accelerated since around 2016 due to the reform of the medical postgraduate education system and the rapid development of Chinese information technology, despite no research explosive period has been yet noted. International institutions, notably the University of Toronto, worked closely with others, while Chinese institutions lacked of international and domestic cooperation. Sixteen stable cooperation clusters of international scholars were formed, while the collaboration between Chinese scholars was not yet stable. XR has been primarily applied in orthopedic surgery, cataract surgery, laparoscopic training and intraoperative use in neurosurgery worldwide.

Conclusions

There is strong enthusiasm and cooperation in the international research on the XR-based surgical training. Chinese scholars are making steady progress and have great potential in this area. There has not been noted an explosive research phase yet in the Chinese pace. The research on several surgical specialties has been summarized at the very first time. AR will gradually to be more involved and take important role of the research.

What are the learning objectives in surgical training - a systematic literature review of the surgical competence framework

OBJECTIVE

To map the landscape of contemporary surgical education through a competence framework by conducting a systematic literature review on learning outcomes of surgical education and the instructional methods applied to attain the outcomes.

BACKGROUND

Surgical education has seen a paradigm shift towards competence-based training. However, a gap remains in the literature regarding the specific components of competency taught and the instructional methods employed to achieve these outcomes. This paper aims to bridge this gap by conducting a systematic review on the learning outcomes of surgical education within a competence framework and the instructional methods applied. The primary outcome measure was to elucidate the components of competency emphasized by modern surgical curricula. The secondary outcome measure was to discern the instructional methods proven effective in achieving these competencies.

METHODS

A search was conducted across PubMed, Medline, ProQuest Eric, and Cochrane databases, adhering to PRISMA guidelines, limited to 2017-2021. Keywords included terms related to surgical education and training. Inclusion criteria mandated original empirical studies that described learning outcomes and methods, and targeted both medical students and surgical residents.

RESULTS

Out of 42 studies involving 2097 participants, most concentrated on technical skills within competency-based training, with a lesser emphasis on non-technical competencies. The effect on clinical outcomes was infrequently explored.

CONCLUSION

The shift towards competency in surgical training is evident. However, further studies on its ramifications on clinical outcomes are needed. The transition from technical to clinical competence and the creation of validated assessments are crucial for establishing a foundation for lifelong surgical learning.

Effectiveness of immersive virtual reality in orthognathic surgical education: A randomized controlled trial

PURPOSE

To evaluate the efficacy of an iVR surgical training system for orthognathic surgery training in medical students.

METHODS

This study comprised 20 fifth year medical students who were randomly assigned to the VR or traditional group for orthognathic surgical education. All participants were initially provided a lecture on orthognathic surgery. The VR group then received 10 educational sessions using the self-developed iVR training system, whereas the traditional group received 10 sessions using technical manuals and annotated operation videos. These sessions were 40-min long in both the groups. Before the evaluation, the traditional group completed one session using the training and assessment modes to become familiar with the iVR training system. The score in the assessment mode, time to complete the procedure, number of instrument selection errors, number of prompts given by the system, number of positional and angular errors, and number of timeouts during each step were recorded to evaluate the learning effect.

RESULTS

The VR group achieved higher scores than the traditional group (94.67 vs. 87.65). Compared with the control group, the VR group completed the procedure more quickly, with fewer instrument selection and angular errors. No difference in the number of prompts given by the system was observed between the two groups.

CONCLUSIONS

The iVR surgical training system showed a better learning effect than the traditional learning method for orthognathic surgery. The iVR surgical training system may have utility as a supplement and potential substitute for the traditional surgical training method.

Performance Evaluation of an Immersive Virtual Reality Application for Rehabilitation after Arthroscopic Rotator Cuff Repair

Few studies have evaluated the effectiveness of shoulder rehabilitation in virtual environments. The objective of this study was to investigate the performance of a custom virtual reality application (VR app) with a stereophotogrammetric system considered the gold standard. A custom VR app was designed considering the recommended rehabilitation exercises following arthroscopic rotator cuff repair. Following the setting of the play space, the user's arm length, and height, five healthy volunteers performed four levels of rehabilitative exercises. Results for the first and second rounds of flexion and abduction displayed low total mean absolute error values and low numbers of unmet conditions. In internal and external rotation, the number of times conditions were not met was slightly higher; this was attributed to a lack of isolated shoulder movement. Data is promising, and volunteers were able to reach goal conditions more often than not. Despite positive results, more literature comparing VR applications with gold-standard clinical parameters is necessary. Nevertheless, results contribute to a body of literature that continues to encourage the application of VR to shoulder rehabilitation programs.

Force Profile as Surgeon-Specific Signature

Objective

To investigate the notion that a surgeon's force profile can be the signature of their identity and performance.

Summary background data

Surgeon performance in the operating room is an understudied topic. The advent of deep learning methods paired with a sensorized surgical device presents an opportunity to incorporate quantitative insight into surgical performance and processes. Using a device called the SmartForceps System and through automated analytics, we have previously reported surgeon force profile, surgical skill, and task classification. However, an investigation of whether an individual surgeon can be identified by surgical technique has yet to be studied.

Methods

In this study, we investigate multiple neural network architectures to identify the surgeon associated with their time-series tool-tissue forces using bipolar forceps data. The surgeon associated with each 10-second window of force data was labeled, and the data were randomly split into 80% for model training and validation (10% validation) and 20% for testing. Data imbalance was mitigated through subsampling from more populated classes with a random size adjustment based on 0.1% of sample counts in the respective class. An exploratory analysis of force segments was performed to investigate underlying patterns differentiating individual surgical techniques.

Results

In a dataset of 2819 ten-second time segments from 89 neurosurgical cases, the best-performing model achieved a micro-average area under the curve of 0.97, a testing F1-score of 0.82, a sensitivity of 82%, and a precision of 82%. This model was a time-series ResNet model to extract features from the time-series data followed by a linearized output into the XGBoost algorithm. Furthermore, we found that convolutional neural networks outperformed long short-term memory networks in performance and speed. Using a weighted average approach, an ensemble model was able to identify an expert surgeon with 83.8% accuracy using a validation dataset.

Conclusions

Our results demonstrate that each surgeon has a unique force profile amenable to identification using deep learning methods. We anticipate our models will enable a quantitative framework to provide bespoke feedback to surgeons and to track their skill progression longitudinally. Furthermore, the ability to recognize individual surgeons introduces the mechanism of correlating outcome to surgeon performance.

Correlational study on novelty factor, immersive tendencies, purchase intention and memory in immersive VR e-commerce applications

E-commerce is a field that changed how consumers purchase and interact with products. Although, inherent limitations such as the difficulty of testing the products "first-hand" before a purchase can compromise consumers' trust in online purchases. Virtual Reality (VR) has been investigated as a tool to solve limitations in several fields and how we can harness its potential to improve the overall user experience. This study analysed how immersive VR (IVR) could solve these limitations by allowing consumers to test products beforehand. We have studied how the Novelty Factor (evaluated by the users' past VR experience) and Immersive Tendencies correlate with the users' Purchase Intention and Memory (how well they remember the product's characteristics). We have analysed a sample of 38 participants (21 males) from 18 to 28 years old. Participants experienced a refrigerator with an interactive touchscreen in an IVR setup and were guided through its functionalities. Results indicated that memory of the product's characteristics was positively correlated with how recently they experienced VR. No correlations were found in the female sample. A negative correlation between Purchase Intention and Memory of the product's characteristics was found in the male sample. We concluded that IVR applications could become helpful for both consumers and online shops in an e-commerce context regardless of the Novelty Factor and Immersive Tendencies of consumers. However, differences between genders should be further investigated.

A virtual reality platform to evaluate the effects of supernumerary limbs' appearance

Supernumerary robot limbs (SL) can expand the ability of users by increasing the number of degrees of freedom that they control. While several SLs have been designed and tested on human participants, the effect of the limb's appearance on the user's acceptance, embodiment and device usage is not yet understood. We developed a virtual reality platform with a three-arm avatar that enabled us to systematically investigate the effect of the supernumerary limb's appearance on their perception and motion control performance. A pilot study with 14 participants exhibited similar performance, workload and preference in human-like or robot-like appearance with a trend of preference for the robotic appearance.

The Changing Environment in Postgraduate Education in Orthopedic Surgery and Neurosurgery and Its Impact on Technology-Driven Targeted Interventional and Surgical Pain Management: Perspectives from Europe, Latin America, Asia, and The United States

Personalized care models are dominating modern medicine. These models are rooted in teaching future physicians the skill set to keep up with innovation. In orthopedic surgery and neurosurgery, education is increasingly influenced by augmented reality, simulation, navigation, robotics, and in some cases, artificial intelligence. The postpandemic learning environment has also changed, emphasizing online learning and skill- and competency-based teaching models incorporating clinical and bench-top research. Attempts to improve work-life balance and minimize physician burnout have led to work-hour restrictions in postgraduate training programs. These restrictions have made it particularly challenging for orthopedic and neurosurgery residents to acquire the knowledge and skill set to meet the requirements for certification. The fast-paced flow of information and the rapid implementation of innovation require higher efficiencies in the modern postgraduate training environment. However, what is taught typically lags several years behind. Examples include minimally invasive tissue-sparing techniques through tubular small-bladed retractor systems, robotic and navigation, endoscopic, patient-specific implants made possible by advances in imaging technology and 3D printing, and regenerative strategies. Currently, the traditional roles of mentee and mentor are being redefined. The future orthopedic surgeons and neurosurgeons involved in personalized surgical pain management will need to be versed in several disciplines ranging from bioengineering, basic research, computer, social and health sciences, clinical study, trial design, public health policy development, and economic accountability. Solutions to the fast-paced innovation cycle in orthopedic surgery and neurosurgery include adaptive learning skills to seize opportunities for innovation with execution and implementation by facilitating translational research and clinical program development across traditional boundaries between clinical and nonclinical specialties. Preparing the future generation of surgeons to have the aptitude to keep up with the rapid technological advances is challenging for postgraduate residency programs and accreditation agencies. However, implementing clinical protocol change when the entrepreneur-investigator surgeon substantiates it with high-grade clinical evidence is at the heart of personalized surgical pain management.

Age and gender effects on presence, user experience and usability in virtual environments-first insights

Virtual Reality (VR) is applied in various areas were a high User Experience is essential. The sense of Presence while being in VR and its relation to User Experience therefore form crucial aspects, which are yet to be understood. This study aims at quantifying age and gender effects on this connection, involving 57 participants in VR, and performing a geocaching game using a mobile phone as experimental task to answer questionnaires measuring Presence (ITC-SOPI), User Experience (UEQ) and Usability (SUS). A higher Presence was found for the older participants, but there was no gender difference nor any interaction effects of age and gender. These findings are contractionary to preexisting limited work which has shown higher Presence for males and decreases of Presence with age. Four aspects discriminating this study from literature are discussed as explanations and as a starting point for future investigations into the topic. The results further showed higher ratings in favor of User Experience and lower ratings towards Usability for the older participants.

Presence and simulator sickness predict the usability of a virtual reality attention task

Attention is the ability to actively process specific information within one's environment over longer periods of time while disregarding other details. Attention is an important process that contributes to overall cognitive performance from performing every day basic tasks to complex work activities. The use of virtual reality (VR) allows study of the attention processes in realistic environments using ecological tasks. To date, research has focused on the efficacy of VR attention tasks in detecting attention impairment, while the impact of the combination of variables such as mental workload, presence and simulator sickness on both self-reported usability and objective attention task performance in immersive VR has not been examined. The current study tested 87 participants on an attention task in a virtual aquarium using a cross-sectional design. The VR task followed the continuous performance test paradigm where participants had to respond to correct targets and ignore non-targets over 18 min. Performance was measured using three outcomes: omission (failing to respond to correct targets), commission errors (incorrect responses to targets) and reaction time to correct targets. Measures of self-reported usability, mental workload, presence and simulator sickness were collected. The results showed that only presence and simulator sickness had a significant impact on usability. For performance outcomes, simulator sickness was significantly and weakly associated with omission errors, but not with reaction time and commission errors. Mental workload and presence did not significantly predict performance. Our results suggest that usability is more likely to be negatively impacted by simulator sickness and lack of presence than performance and that usability and attention performance are linked. They highlight the importance of considering factors such as presence and simulator sickness in attention tasks as these variables can impact usability.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10055-023-00782-3.

Current status of virtual reality simulation education for orthopedic residents: the need for a change in focus

Introduction

Advances in technology are changing surgical education. Simulation provides an important adjunct to operative experience. This pedagogy has arguably become more important in light of the COVID-19 pandemic, with resultant reduction in operative exposure for trainees. Virtual reality (VR) simulators may provide significant contribution to experiential learning; however, much of the investigative focus to date has, correctly, been on establishing validity evidence for these constructs. The aim of this work was to perform a scoping review to assess the current status of VR simulation education to determine curricular development efforts for orthopedic residents.

Methods

With a trained medical librarian, searches of PubMed, EMBASE, and Web of Science were conducted for all articles in the last 10 years (September 2011-September 2021). Controlled vocabulary Medical Subject Headings (MeSH) terms and natural language developed with subject matter experts describing virtual reality or VR simulation and orthopedic training were used. Two trained reviewers evaluated all abstracts for inclusion. Exclusion criteria were all articles that did not assess VR simulation education involving orthopedic residents. Data were extracted from the included full-text articles including: study design, type of participants, type of VR simulation, simulated orthopedic skill, type of educational event, learner assessment including Kirkpatrick's level, assessment of quality using the Medical Education Research Study Quality Instrument (MERSQI), and level of effectiveness (LoE).

Results

Initial search identified 1,394 articles, of which 61 were included in the final qualitative synthesis. The majority (54%) were published in 2019- 2021, 49% in Europe. The commonest VR simulator was ArthroS (23%) and the commonest simulated skill was knee arthroscopy (33%). The majority of studies (70%) focused on simulator validation. Twenty-three studies described an educational module or curriculum, and of the 21 (34%) educational modules, 43% were one-off events. Most modules (18/21, 86%) assessed learners at Kirkpatrick level 2. With regard to methodological quality, 44% of studies had MERSQI 11.5-15 and 89% of studies had LoE of 2. Two studies had LoE of 3.

Conclusion

Current literature pertaining to VR training for orthopedic residents is focused on establishing validity and rarely forms part of a curriculum. Where the focus is education, the majority are discrete educational modules and do not teach a comprehensive amalgam of orthopedic skills. This suggests focus is needed to embed VR simulation training within formal curricula efforts guided by the work of Kern, and assess the efficacy of these against patient outcomes.

Application of Virtual Reality Systems in Bone Trauma Procedures

Background and Objectives: Bone fractures contribute significantly to the global disease and disability burden and are associated with a high and escalating incidence and tremendous economic consequences. The increasingly challenging climate of orthopaedic training and practice re-echoes the established potential of leveraging computer-based reality technologies to support patient-specific simulations for procedural teaching and surgical precision. Unfortunately, despite the recognised potential of virtual reality technologies in orthopaedic surgery, its adoption and integration, particularly in fracture procedures, have lagged behind other surgical specialities. We aimed to review the available virtual reality systems adapted for orthopaedic trauma procedures. Materials and Methods: We performed an extensive literature search in Medline (PubMed), Science Direct, SpringerLink, and Google Scholar and presented a narrative synthesis of the state of the art on virtual reality systems for bone trauma procedures. Results: We categorised existing simulation modalities into those for fracture fixation techniques, drilling procedures, and prosthetic design and implantation and described the important technical features, as well as their clinical validity and applications. Conclusions: Over the past decade, an increasing number of high- and low-fidelity virtual reality systems for bone trauma procedures have been introduced, demonstrating important benefits with regard to improving procedural teaching and learning, preoperative planning and rehearsal, intraoperative precision and efficiency, and postoperative outcomes. However, further technical developments in line with industry benchmarks and metrics are needed in addition to more standardised and rigorous clinical validation.

The role of virtual reality in knee arthroscopic simulation: a systematic review

PURPOSE

Surgical training is crucial for orthopedics residents during their educational careers. Residents who follow classic training courses are less skilled than those trained with simulators. Virtual simulators are reported to be global learning tools for knee arthroscopy. The primary purpose of our study is to evaluate the current state of use of arthroscopic knee simulators and their actual effectiveness in transfer the skills learned in training to the operating theatre. The secondary purpose is to evaluate if the virtual simulators are better than the others in improve arthroscopic skills.

METHODS

Studies involving knee arthroscopy training with virtual reality simulators were included: a search of the literature from 2009 to September 2019 was performed on MEDLINE(PubMed) using PRISMA guidelines. Exclusion criteria were systematic review articles, aims and topics not related to the purpose of the study, single case and technical reports, biomechanical analysis, articles not in the English language, and editorial commentaries.

RESULTS

The literature review selected, nine studies and they included results on 93 residents, three expert surgeons and 189 medical students. All studies report improved arthroscopic skills after training with a simulator. Only four studies evaluated the transfer of arthroscopic skills of knee simulators to the operating theatre.

CONCLUSIONS

Benchtop and Virtual Reality simulators are excellent tools for accelerating and improving arthroscopic training and skills acquisition. The second ones, high-cost, and fidelity simulators, seem to be the best of the two. A greater diffusion of Virtual Reality in universities is to be considered to improve residents' training and patients' clinical outcomes.

Effective Skill Transfer From Fundamentals of Arthroscopic Surgery Training to Shoulder Arthroscopic Simulator in Novices

PURPOSE

To investigate whether novices could improve performance on a shoulder arthroscopic simulator (high-fidelity) through short-term training on a Fundamentals of Arthroscopic Surgery Training (FAST) simulator (low-fidelity).

METHODS

Twenty-eight novices with no experience in arthroscopy were recruited to perform a pre-test on a shoulder arthroscopic simulator. Then they were randomized into two groups: the experimental group practiced five modules on the FAST simulator three times, and the control group did nothing. The experimental group performed a post-test immediately after FAST simulator practice. Control group rested for 70 minutes after experiencing pre-test before performing post-test. All parameters were recorded by the simulator.

RESULTS

The experimental group outperformed the control group in terms of total score, procedure time, camera path length, and grasper path length. However, there was no statistical difference in scratching of humerus cartilage or glenoid cartilage. Significant differences were found in the improvement of both groups in total score, procedure time, and camera path length.

CONCLUSIONS

Arthroscopic skills gained after short-term training on FAST simulator could be transferred to the shoulder arthroscopic simulator. This research provides important evidence of the benefits of FAST simulator in shoulder arthroscopy training program.

Comparison of virtual reality and physical simulation training in first-year radiography students in South America

INTRODUCTION

The aim of this study was to comparatively evaluate the learning outcomes achieved by first-year radiography students educated with either virtual reality (VR) simulation training or physical simulation training. The implementation of VR has been proposed to enhance learning in radiography students and provide a more effective and efficient approach to simulation. However, the learning outcomes achieved with this approach have not been widely investigated.

METHODS

Through stratified randomisation, 188 radiography students were allocated to one of two matched groups: a VR group (using Virtual Medical Coaching's Radiography simulation) and a physical simulation group (using Philips' X-ray equipment). Both groups were taught 31 radiography views over one 25-week semester. Both groups were assessed in an Objective Structured Clinical Examination (OSCE), using actors as patients in a physical X-ray environment. Assessment was conducted by assigning objective count scores for five assessment criteria.

RESULTS

The VR group achieved shorter OSCE duration and fewer errors in moving equipment and patient positioning: these results were statistically significant (P < 0.00). There was no significant difference in the frequency of errors in radiographic exposure setting between the VR and the physical simulation group. The current findings concur with the limited number of published studies concerning VR simulation in radiography.

CONCLUSIONS

The results of this study demonstrated superior effectiveness and efficiency in the VR group. This provides preliminary evidence to introduce VR simulation in the host institution and provide evidence that it may be possible to replace the use of physical simulation across other years of the degree. Further research investigating these possibilities is warranted.

Bringing Radiology Education to a New Reality: A Pilot Study of Using Virtual Reality as a Remote Educational Tool

Purpose: We investigated virtual reality (VR) during a 2-week, undergraduate, radiology elective to determine if it improved learning outcomes and user satisfaction. Methods: Eighteen students enrolled between August 2021 and February 2022. Each student had a collaborative Zoom teaching session with a preceptor using a Picture Archive and Communications System (PACS)-like viewing system Online DICOM Image Navigator (ODIN), followed by a teaching session using a VR, Digital Imaging and Communications in Medicine (DICOM) viewer (SieVRt). After each teaching session, the students independently reviewed 8 imaging cases and completed case related questions. The students completed a survey, rating their subjective experiences using ODIN and SieVRt. Results: There was no difference in total test scores between the two learning strategies. However, students did perform statistically better on two of five questions designed to test the detection/measurement capabilities of SieVRt vs ODIN. Students stated that they preferred using SieVRt over ODIN and agreed that they were able to view subtle imaging findings and abnormalities better using SieVRt. However, students found that some of the functions of SieVRt (measuring angles/lengths, and multitasking) were difficult. There were technical challenges with VR and minor undesirable physical effects (dizziness, nausea, etc.). Conclusions: Virtual reality has the potential to enhance radiology education by providing an immersive and engaging experience. Objectively, students were able to perform two tasks better with SieVRt. Subjectively, the VR platform received favourable reviews from students for a variety of features. There were reported technical and physical challenges related to using VR. Future developments in VR systems should focus on improving the user experience.

Piezoelectric Micromachined Ultrasonic Transducers (PMUTs): Performance Metrics, Advancements, and Applications

With the development of technology, systems gravitate towards increasing in their complexity, miniaturization, and level of automation. Amongst these systems, ultrasonic devices have adhered to this trend of advancement. Ultrasonic systems require transducers to generate and sense ultrasonic signals. These transducers heavily impact the system's performance. Advancements in microelectromechanical systems have led to the development of micromachined ultrasonic transducers (MUTs), which are utilized in miniaturized ultrasound systems. Piezoelectric micromachined ultrasonic transducers (PMUTs) exhibit higher capacitance and lower electrical impedance, which enhances the transducer's sensitivity by minimizing the effect of parasitic capacitance and facilitating their integration with low-voltage electronics. PMUTs utilize high-yield batch microfabrication with the use of thin piezoelectric films. The deposition of thin piezoelectric material compatible with complementary metal-oxide semiconductors (CMOS) has opened novel avenues for the development of miniaturized compact systems with the same substrate for application and control electronics. PMUTs offer a wide variety of applications, including medical imaging, fingerprint sensing, range-finding, energy harvesting, and intrabody and underwater communication links. This paper reviews the current research and recent advancements on PMUTs and their applications. This paper investigates in detail the important transduction metrics and critical design parameters for high-performance PMUTs. Piezoelectric materials and microfabrication processes utilized to manufacture PMUTs are discussed. Promising PMUT applications and outlook on future advancements are presented.

A virtual surgical prototype system based on gesture recognition for virtual surgical training in maxillofacial surgery

Background

Virtual reality (VR) technology is an ideal alternative of operation training and surgical teaching. However, virtual surgery is usually carried out using the mouse or data gloves, which affects the authenticity of virtual operation. A virtual surgery system with gesture recognition and real-time image feedback was explored to realize more authentic immersion.

Method

Gesture recognition technology proposed with an efficient and real-time algorithm and high fidelity was explored. The recognition of hand contour, palm and fingertip was firstly realized by hand data extraction. Then, an Support Vector Machine classifier was utilized to classify and recognize common gestures after extraction of feature recognition. The algorithm of collision detection adopted Axis Aligned Bounding Box binary tree to build hand and scalpel collision models. What’s more, nominal radius theorem (NRT) and separating axis theorem (SAT) were applied for speeding up collision detection. Based on the maxillofacial virtual surgical system we proposed before, the feasibility of integration of the above technologies in this prototype system was evaluated.

Results

Ten kinds of signal static gestures were designed to test gesture recognition algorithms. The accuracy of gestures recognition is more than 80%, some of which were over 90%. The generation speed of collision detection model met the software requirements with the method of NRT and SAT. The response time of gesture] recognition was less than 40 ms, namely the speed of hand gesture recognition system was greater than 25 Hz. On the condition of integration of hand gesture recognition, typical virtual surgical procedures including grabbing a scalpel, puncture site selection, virtual puncture operation and incision were carried out with realization of real-time image feedback.

Conclusion

Based on the previous maxillofacial virtual surgical system that consisted of VR, triangular mesh collision detection and maxillofacial biomechanical model construction, the integration of hand gesture recognition was a feasible method to improve the interactivity and immersion of virtual surgical operation training.

Meditation Using a Mobile App Improves Surgery Trainee Performance: a simulation-based randomized controlled trial

PURPOSE

To primarily investigate: (1) whether a 10 min instant meditation practice using mobile app could enhance arthroscopy performance and (2) whether a 10-day app-based meditation could reduce short-term arthroscopic skills deterioration.

METHODS

Orthopedic residents with no previous experience in arthroscopy and meditation were randomly assigned to Groups A, B, and C. After initial standard competency-based arthroscopy training on the simulator on Day 1, a pretest was performed via simulator by all participants to assess their initial level of performance, then Groups A and B were required to practice app-based mindfulness meditation 10 min/day for 10 consecutive days, while Group C did nothing. On Day 11, all participants came back to perform a posttest. Prior to the posttest, the participants in Group A practiced app-based meditation (10 min) , whereas Groups B and C had no intervention.

RESULTS

43 participants were included and reached similar level of performance after initial training phase in Day1. In Day11, participants in Group A had statistically better instant arthroscopy performance than Group B, with higher total score (Mean Difference, 3.57; P<.001), less completion time (MD, -42.89s; P=.001), shorter camera (MD, -23.38cm; P<.001) and grasper (MD, -15.23cm; P=.002) path length and less cartilage injury (MD, -1.07%; P=.012). Participants in Group B had less skills deterioration than Group C, with better total score (MD, -5.42; P<.001), less completion time (MD, 51.96s; P=.002), camera path length (MD, 28.41cm; P=.007) and cartilage injury (MD, 1.19%; P=.038).

CONCLUSION

Meditation training using mobile app enhanced instant simulation-based arthroscopy performance and reduced short-term skills deterioration of orthopedic residents with no arthroscopy hands-on experience.

CLINICAL RELEVANCE

Meditation using mobile app for clinicians and educators should be incorporated into simulation-based arthroscopy curriculums and perhaps clinical settings to improve arthroscopy performance and mental health of orthopedic residents without any prior arthroscopy experience.

Development and Validation of SCFE Percutaneous Pinning Surgical Simulation

BACKGROUND

In situ screw fixation with a single percutaneously placed femoral screw remains widely accepted for femoral head fixation in adolescent patients with slipped capital femoral epiphysis (SCFE). Given the potential risks involved with this procedure, a simulation whereby surgical skills could be refined before entering the operating room may be of benefit to orthopaedic trainees.

METHODS

We developed a synthetic model for the simulated treatment of SCFE. Five orthopaedic attendings and twenty trainees were recorded performing an in situ percutaneous fixation on the SCFE model. Time, radiation exposure, and final anteroposterior and lateral radiographs of the SCFE model were recorded. After completion, the attendings and trainees answered a Likert-based questionnaire regarding the realism and utility of the simulation, respectively. Two blinded orthopaedic surgeons rated each participant's skill level based on previously described assessment tools, including a Global Rating Scale (GRS) of technical proficiency and radiographic grading index for screw placement. Performance metrics and survey responses were evaluated for construct validity, face validity, and interrater reliability.

RESULTS

The attendings demonstrated superior technical proficiency compared with trainees in terms of higher GRS scores (27.9±1.9 vs. 14.7±5.0, P<0.001) and better radiographic grading of screw placement on lateral views (P=0.019). Similarly, compared with the trainees, the orthopaedic attendings demonstrated shorter operative times (11.0±4.1 vs. 14.7±6.2 min, P=0.035) and less radiation exposure (3.7±1.7 vs. 9.5±5.7 mGy, P=0.037). The interrater reliability was excellent for both the GRS scoring (intraclass correlation coefficient=0.973) and radiographic grading (weighted κ=1.000). The attendings and trainees rated the realism and teaching utility of the simulation as "very good," respectively.

CONCLUSION

Our surgical simulation for in situ percutaneous fixation of SCFE represents a valid and reliable measure of technical competency and demonstrates much promise for potential use as a formative educational tool for orthopaedic residency programs.

LEVEL OF EVIDENCE

Level II.

The Study of Immersive Physiology Courses Based on Intelligent Network through Virtual Reality Technology in the Context of 5G

The current boom in Internet technology has paved the way for the research and evolution of various technologies related to it. One such technology is immersive virtual reality (IVR). Immersive technology is referred to as creating a reality-like experience by combining the physical world with digital reality. There are two main types of immersive technologies. Immersion in virtual reality is the perception of being physically present in an artificially created world. Perception is artificially created by images, videos, sounds, or other stimuli with the help of a virtual reality (VR) system that the user is connected to. VR uses rendered computer-generated simulations and results in a complete sense of immersion. Immersive virtual reality (immersive VR) refers to engaging users in an artificial environment that replaces their natural surroundings and fully engages them with the artificially created environment. In this research, we will research immersive physiology courses based on artificial intelligence combined with wireless network VR technology in the context of 5G. The teaching methodology has been kept up-to-date along with the technology. Teaching physiology courses also incorporate new technologies like immersive technologies. The use of technology in anatomy and physiology courses allows students to view structures and physiological concepts in a realistic environment. Virtual dissection in 3D is available with a life-like artificial environment. Students can attend the classes with VR headsets, laptops, or smartphones to experience immersive and interactive 3D classes. This advanced technology enhances and empowers the students to learn from real-life situations like those available in the classes. In this research, CNN with AI is proposed for effective learning of physiology courses. This algorithm is compared with the existing NNGA, KNN, and Random Forest, and it is observed that the proposed model has obtained an accuracy of 99%.

Artificial intelligence in knee arthroplasty: current concept of the available clinical applications

Background

Artificial intelligence (AI) is defined as the study of algorithms that allow machines to reason and perform cognitive functions such as problem-solving, objects, images, word recognition, and decision-making. This study aimed to review the published articles and the comprehensive clinical relevance of AI-based tools used before, during, and after knee arthroplasty.

Methods

The search was conducted through PubMed, EMBASE, and MEDLINE databases from 2000 to 2021 using the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA).

Results

A total of 731 potential articles were reviewed, and 132 were included based on the inclusion criteria and exclusion criteria. Some steps of the knee arthroplasty procedure were assisted and improved by using AI-based tools. Before surgery, machine learning was used to aid surgeons in optimizing decision-making. During surgery, the robotic-assisted systems improved the accuracy of knee alignment, implant positioning, and ligamentous balance. After surgery, remote patient monitoring platforms helped to capture patients’ functional data.

Conclusion

In knee arthroplasty, the AI-based tools improve the decision-making process, surgical planning, accuracy, and repeatability of surgical procedures.

Ten hours of simulator training in arthroscopy are insufficient to reach the target level based on the Diagnostic Arthroscopic Skill Score

PURPOSE

Simulator arthroscopy training has gained popularity in recent years. However, it remains unclear what level of competency surgeons may achieve in what time frame using virtual training. It was hypothesized that 10 h of training would be sufficient to reach the target level defined by experts based on the Diagnostic Arthroscopic Skill Score (DASS).

METHODS

The training concept was developed by ten instructors affiliated with the German-speaking Society of Arthroscopy and Joint Surgery (AGA). The programme teaches the basics of performing arthroscopy; the main focus is on learning and practicing manual skills using a simulator. The training was based on a structured programme of exercises designed to help users reach defined learning goals. Initially, camera posture, horizon adjustment and control of the direction of view were taught in a virtual room. Based on these skills, further training was performed with a knee model. The learning progress was assessed by quantifying the exercise time, camera path length and instrument path length for selected tasks. At the end of the course, the learners' performance in diagnostic arthroscopy was evaluated using DASS. Participants were classified as novice or competent based on the number of arthroscopies performed prior to the assessment.

RESULTS

Except for one surgeon, 131 orthopaedic residents and surgeons (29 women, 102 men) who participated in the seven courses agreed to anonymous data analysis. Fifty-eight of them were competents with more than ten independently performed arthroscopies, and 73 were novices, with fewer than ten independently performed arthroscopies. There were significant reductions in exercise time, camera path length and instrument path length for all participants after the training, indicating a rapid increase in performance. No difference in camera handling between the dominant and non-dominant sides was found in either group. The competents performed better than the novices in various tasks and achieved significantly better DASS values on the final performance test.

CONCLUSIONS

Our data have demonstrated that arthroscopic skills can be taught effectively on a simulator, but a 10-h course is not sufficient to reach the target level set by experienced arthroscopists. However, learning progress can be monitored more objectively during simulator training than in the operating room, and simulation may partially replace the current practice of arthroscopic training.

LEVEL OF EVIDENCE

III.

Is the Virtual Reality Fundamentals of Arthroscopic Surgery Training Program a Valid Platform for Resident Arthroscopy Training?

BACKGROUND

Training in arthroscopy is associated with a steep learning curve for trainees and bears risks for patients. Virtual reality (VR) arthroscopy simulation platforms seek to overcome this and to provide a safe environment for surgical learners. The Fundamentals of Arthroscopic Surgery Training (FAST) program is one such platform. It is currently not known whether the VR FAST program can be employed as a useful teaching or examination tool to assess the basic arthroscopic skills of surgical trainees.

QUESTIONS/PURPOSES

(1) Does the VR FAST program differentiate among novice, intermediate, and expert arthroscopists? (2) Does ambidextrous performance in the VR FAST program correlate with arthroscopic experience?

METHODS

We prospectively recruited orthopaedic interns (novices), residents (intermediates), and fellows and attendings (experts) to complete the VR FAST program over a 1-year period from four major orthopaedic training programs on a voluntary basis. Sixty-six of 156 invited orthopaedic surgeons participated: 26 of 50 novices (16 men and 10 women), 27 of 65 intermediates (20 men and seven women), and 13 of 41 experts (10 men and three women). Surgeons of any arthroscopic experience were included, with only those with prior experience on the VR FAST program being excluded. The program consists of eight modules: three basic camera modules (Image Centering, Horizon Control, and Telescoping), three advanced camera modules (Periscoping, Trace the Line, and Trace the Curve), and two instrumented bimanual-dexterity modules (Probe Triangulation and Gather the Stars). Time taken to complete each task and measures of economy of movement (camera and instrument path length, camera alignment) were used as measures of arthroscopic experience. Every participant completed the modules using their dominant and nondominant hands. Equality in proficiency in completing the tasks using the dominant and nondominant hands were determined to be measures of arthroscopic experience. Due to the large number of outcome variables, only p values < 0.01 were considered to be statistically significant.

RESULTS

Six of eight VR FAST modules did not discriminate among novice, intermediate, and expert arthroscopy participants. However, two did, and the ones that were most effective at distinguishing participants by level of experience were the Periscoping and Gather the Stars modules. For the Periscoping module using the dominant hand, novices required longer to complete the task with a median time of 231 seconds (IQR 149 to 358) and longer camera path length median of 191 cm (IQR 128 to 273) compared with intermediates who needed 127 seconds (IQR 106 to 233) and 125 cm (IQR 92 to 159) and experts who needed 121 seconds (IQR 93 to 157) and 119 cm (IQR 90 to 134) (p = 0.001 and p = 0.003, respectively). When using the nondominant hand, novices took longer to complete the task with a median time of 231 seconds (IQR 170 to 350) and longer camera path length 204 cm (IQR 169 to 273) compared with intermediates who required 132 seconds (IQR 97 to 162) and 111 cm (IQR 88 to 143) and experts who needed 119 seconds (IQR 104 to 183) and 120 cm (IQR 108 to 166) (p < 0.001 and p < 0.001, respectively). For the Gather the Stars module using the nondominant hand, only the novices needed longer to complete the task at a median of 131 seconds (IQR 112 to 157) and needed a longer grasper path length of 290 cm (IQR 254 to 332) compared with intermediates who needed 84 seconds (IQR 72 to 119) and 232 cm (IQR 195 to 254) and experts who needed 98 seconds (IQR 87 to 107) and 244 cm (IQR 215 to 287) (p < 0.001 and p = 0.001, respectively).

CONCLUSION

Six of eight VR FAST modules did not demonstrate construct validity, and we found no correlation between arthroscopic experience and ambidextrous performance. Two modules demonstrated construct validity; however, refinement and expansion of the modules is needed with further validation in large prospective trials so that pass-fail thresholds can be set for use in high-stakes examinations.

CLINICAL RELEVANCE

Most VR FAST modules were not discriminatory; however, they can form essential conceptual and procedural building blocks in an arthroscopic curriculum that are beneficial for novices when developing key psychomotor skills. In their present format, however, they are unsuitable for assessing arthroscopic proficiency.

Digital Education for Health Professionals: An Evidence Map, Conceptual Framework, and Research Agenda

BACKGROUND

Health professions education has undergone major changes with the advent and adoption of digital technologies worldwide.

OBJECTIVE

This study aims to map the existing evidence and identify gaps and research priorities to enable robust and relevant research in digital health professions education.

METHODS

We searched for systematic reviews on the digital education of practicing and student health care professionals. We searched MEDLINE, Embase, Cochrane Library, Educational Research Information Center, CINAHL, and gray literature sources from January 2014 to July 2020. A total of 2 authors independently screened the studies, extracted the data, and synthesized the findings. We outlined the key characteristics of the included reviews, the quality of the evidence they synthesized, and recommendations for future research. We mapped the empirical findings and research recommendations against the newly developed conceptual framework.

RESULTS

We identified 77 eligible systematic reviews. All of them included experimental studies and evaluated the effectiveness of digital education interventions in different health care disciplines or different digital education modalities. Most reviews included studies on various digital education modalities (22/77, 29%), virtual reality (19/77, 25%), and online education (10/77, 13%). Most reviews focused on health professions education in general (36/77, 47%), surgery (13/77, 17%), and nursing (11/77, 14%). The reviews mainly assessed participants' skills (51/77, 66%) and knowledge (49/77, 64%) and included data from high-income countries (53/77, 69%). Our novel conceptual framework of digital health professions education comprises 6 key domains (context, infrastructure, education, learners, research, and quality improvement) and 16 subdomains. Finally, we identified 61 unique questions for future research in these reviews; these mapped to framework domains of education (29/61, 47% recommendations), context (17/61, 28% recommendations), infrastructure (9/61, 15% recommendations), learners (3/61, 5% recommendations), and research (3/61, 5% recommendations).

CONCLUSIONS

We identified a large number of research questions regarding digital education, which collectively reflect a diverse and comprehensive research agenda. Our conceptual framework will help educators and researchers plan, develop, and study digital education. More evidence from low- and middle-income countries is needed.

Efficacy of virtual reality techniques in cardiopulmonary resuscitation training: protocol for a meta-analysis of randomised controlled trials and trial sequential analysis

INTRODUCTION

Cardiopulmonary resuscitation (CPR) is the most critical procedure in the rescue of patients with sudden cardiac death (SCD). The success rate of CPR remains far below expectations, which made CPR education identified as the top priority for SCD. CPR training using the virtual reality (VR) technique is a feasible training method, with a wider population and lower cost, but its efficacy remains controversial. Thus, we will perform a protocol for a systematic review and meta-analysis to identify the efficacy of the VR technique on CPR quality.

METHODS AND ANALYSIS

We will search PubMed, Web of Science, Cochrane Library, Ovid Medline, Embase, China National Knowledge Infrastructure, Chinese BioMedical Literature, Wanfang and VIP databases from inception to November 2021, to identify randomised controlled trials and the first period in randomised cross-over trials assessing the efficacy of VR techniques versus non-VR techniques for adult participants accepting adult CPR training. No language restrictions will be considered. Data synthesis will be performed using RevMan V.5.4 and Stata/MP V.16.0. Outcome measures will be present as relative risk with 95% CIs for dichotomous data and mean difference with 95% CIs for continuous data. The primary outcome will be the CPR quality defined as chest compression rate and depth. Secondary outcomes will be the overall performance of CPR. Heterogeneity will be assessed by the χ² test and I² statistic. Data will be synthesised by either fixed-effects or random-effects models according to the I² value. Trial sequential analysis and modified Jadad Scale will be used to control the risks of random errors and evaluate the evidence quality. Egger's regression test and funnel plots will be used to assess the publication bias.

ETHICS AND DISSEMINATION

Ethical approval was not required for this systematic review protocol. The findings will be disseminated through peer-reviewed publications.

PROSPERO REGISTRATION NUMBER

CRD42021281059.

Virtual Reality in Medical Students' Education: Scoping Review

BACKGROUND

Virtual reality (VR) produces a virtual manifestation of the real world and has been shown to be useful as a digital education modality. As VR encompasses different modalities, tools, and applications, there is a need to explore how VR has been used in medical education.

OBJECTIVE

The objective of this scoping review is to map existing research on the use of VR in undergraduate medical education and to identify areas of future research.

METHODS

We performed a search of 4 bibliographic databases in December 2020. Data were extracted using a standardized data extraction form. The study was conducted according to the Joanna Briggs Institute methodology for scoping reviews and reported in line with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines.

RESULTS

Of the 114 included studies, 69 (60.5%) reported the use of commercially available surgical VR simulators. Other VR modalities included 3D models (15/114, 13.2%) and virtual worlds (20/114, 17.5%), which were mainly used for anatomy education. Most of the VR modalities included were semi-immersive (68/114, 59.6%) and were of high interactivity (79/114, 69.3%). There is limited evidence on the use of more novel VR modalities, such as mobile VR and virtual dissection tables (8/114, 7%), as well as the use of VR for nonsurgical and nonpsychomotor skills training (20/114, 17.5%) or in a group setting (16/114, 14%). Only 2.6% (3/114) of the studies reported the use of conceptual frameworks or theories in the design of VR.

CONCLUSIONS

Despite the extensive research available on VR in medical education, there continue to be important gaps in the evidence. Future studies should explore the use of VR for the development of nonpsychomotor skills and in areas other than surgery and anatomy.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2020-046986.

Incorporation of virtual reality in the clinical training of medical students studying esophageal and mediastinal anatomy and surgery

PURPOSE

To analyze the effectiveness of incorporating virtual reality (VR) in lectures on esophageal and mediastinal anatomy and surgical procedures for medical students at Gifu University during clinical training.

METHODS

We divided medical students participating in clinical training, randomly, into two groups of 30 students each: those who received a lecture using 3D images (3D group) and those who received a lecture using VR images (VR group). Four days after the lecture, the students completed a written test to allow us to evaluate their comprehension, and a questionnaire on their opinion of the lectures.

RESULTS

Based on the results of the written test, the VR group achieved better understanding of computed tomography (CT) images (p = 0.0001) and better interpretation of surgical images (p = 0.0163). However, there was no difference in the scores for spatial recognition and general problems. The questionnaire revealed that the VR group became more interested in mediastinal anatomy (p = 0.0165) and surgery (p = 0.0135).

CONCLUSIONS

Our findings suggest that VR enhances the learning process. The lecture incorporating the VR experience was more effective than the traditional lecture for promoting an understanding of CT images and interpretation of surgical images; thus, it enhances the learning experience for medical students studying surgery.

Virtual reality surgical planning for endoscopic endonasal approaches to the craniovertebral junction

PURPOSE

To demonstrate the utility of virtual reality (VR) for preoperative surgical planning of endoscopic endonasal craniovertebral junction (CVJ) surgery.

MATERIALS AND METHODS

Five patients who had undergone endoscopic endonasal surgery of the craniovertebral junction with preoperative virtual reality surgical planning were identified and described.

RESULTS

The anterior approach to the CVJ has been traditionally accomplished transorally. However, recently the transnasal endoscopic approach to this location has been described. Multiple anatomical studies have been conducted using the nasopalatine, nasoaxial, and rhinopalatine lines (NPL, NAxL, RPL) in an attempt to preoperatively delineate the inferior limits of endoscopic dissection. The use of advanced surgical simulation using immersive virtual reality is an innovative approach for analyzing CVJ anatomy and developing a surgical plan. VR simulation through the use of interactive and highly accurate patient specific models allows for the creation of three-dimensional (3D) digital reconstructions via the fusion of CT and MRI studies. Incorporation of simulation technology has been shown to increase surgeon proficiency while simultaneously decreasing complication rates. The described case series demonstrates the novel utility of VR planning for designing the endoscopic surgical approach to the CVJ.

CONCLUSIONS

VR technology allows for the creation of anatomically accurate 3D models that can be used for preoperative planning of endoscopic endonasal surgery. Such models help in the development of safe surgical plans by predicting inferior and lateral planes of dissection and assisting in the identification of critical structures.

Validation of virtual reality arthroscopy simulator relevance in characterising experienced surgeons

BACKGROUND

Virtual reality (VR) simulation is particularly suitable for learning arthroscopy skills. Despite significant research, one drawback often outlined is the difficulty in distinguishing performance levels (Construct Validity) in experienced surgeons. Therefore, it seems adequate to search new methods of performance measurements using probe trajectories instead of commonly used metrics.

HYPOTHESIS

It was hypothesized that a larger experience in surgical shoulder arthroscopy would be correlated with better performance on a VR shoulder arthroscopy simulator and that experienced operators would share similar probe trajectories.

MATERIALS & METHODS

After answering to standardized questionnaires, 104 trajectories from 52 surgeons divided into 2 cohorts (26 intermediates and 26 experts) were recorded on a shoulder arthroscopy simulator. The procedure analysed was the "loose body removal" in a right shoulder joint. 10 metrics were computed on the trajectories including procedure duration, overall path length, economy of motion and smoothness. Additionally, Dynamic Time Warping (DTW) was computed on the trajectories for unsupervised hierarchical clustering of the surgeons.

RESULTS

Experts were significantly faster (Median 70.9s Interquartile range [56.4-86.3] vs. 116.1s [82.8-154.2], p<0.01), more fluid (4.6.10⁵mm.s^-3 [3.1.10⁵-7.2.10⁵] vs. 1.5.10⁶mm.s^-3 [2.6.10⁶-3.5.10⁶], p=0.05), and economical in their motion (19.3mm² [9.1-25.9] vs. 33.8mm² [14.8-50.5], p<0.01), but there was no significant difference in performance for path length (671.4mm [503.8-846.1] vs 694.6mm [467.0-1090.1], p=0.62). The DTW clustering differentiates two expertise related groups of trajectories with performance similarities, respectively including 48 expert trajectories for the first group and 52 intermediates and 4 expert trajectories for the second group (Sensitivity of 92%, Specificity of 100%). Hierarchical clustering with DTW significantly identified expert operators from intermediate operators and found trajectory similarities among 24/26 experts.

CONCLUSION

This study demonstrated the Construct Validity of the VR shoulder arthroscopy simulator within groups of experienced surgeons. With new types of metrics simply based on the simulator's raw trajectories, it was possible to significantly distinguish levels of expertise. We demonstrated that clustering analysis with Dynamic Time Warping was able to reliably discriminate between expert operators and intermediate operators.

CLINICAL RELEVANCE

The results have implications for the future of arthroscopic surgical training or post-graduate accreditation programs using virtual reality simulation.

LEVEL OF EVIDENCE

III; prospective comparative study.

Virtual and augmented reality for surgical training and simulation in knee arthroplasty

BACKGROUND

Immersive virtual reality (IVR), augmented reality and mixed reality form a spectrum of extended reality technology integration that has gained popularity in orthopaedics recently. This review article examines the role of extended reality technologies in knee arthroplasty.

METHODS

Existing literature on the applications of extended reality technologies in preoperative planning and intraoperative navigation were reviewed. A sample workflow of a novel IVR simulator for improving surgical training was also provided to demonstrate its utility in educating trainees on knee arthroplasty techniques.

RESULTS

Extended reality technologies enable the surgeon to visualise patient-specific anatomy in real-time, enhancing preoperative planning and providing intraoperative guidance. IVR technology has the potential to revolutionise modern surgical training and optimise surgical performance in a cost-efficient manner, with current evidence demonstrating favourable immediate skill acquisition and transfer.

CONCLUSIONS

Extended reality technologies have a myriad of potential applications in orthopaedic surgery. Further research is needed to evaluate the cost-effectiveness of its incorporation into training programmes.

Virtual Reality in Orthopedic Surgery Training

One emerging technology with the potential to improve and further transform the field of orthopaedic surgery is virtual reality (VR). VR has been explored and used in many different specialties with clinical applications, such as psychiatric therapy, pain management, rehabilitation, and traumatic brain injury. Recent studies have suggested that the use of VR during the training of orthopaedic surgery residents produces similar or improved surgical performance by residents. This is an area where VR can provide a tremendous benefit to the field of orthopaedic surgery, as it offers a safe and accessible complement to orthopaedic surgical training outside of the operating room (OR) and without involving patients directly. This review will elucidate the current state of virtual reality use in the training of orthopaedic surgeons and highlight key benefits and challenges in its application as a training resource.

Clinical Ultrasound Education for Medical Students: Virtual Reality Versus e-Learning, a Randomized Controlled Pilot Trial

ABSTRACT

The primary aim was to evaluate the effect of immersive virtual reality learning for training medical students in basic clinical ultrasound. Secondary outcomes were to explore if virtual reality learning had an effect on hand-eye coordination skills and if the medical students wanted more virtual reality learning.This pilot study was a double-blind, parallel-group, block-randomized, controlled trial. Participants (n = 20) were blinded and randomized to virtual reality or e-learning for basic ultrasound education. Medical students with no previous ultrasound education were recruited voluntarily from the University of Southern Denmark. Data were collected during introductory courses on ultrasound from March to May 2019. Participants were assessed with Objective Structured Assessment on Ultrasound Skills. Assessing supervisors were blinded.The virtual reality group (n = 11) scored a significantly higher Objective Structured Assessment on Ultrasound Skills score (143 [95% confidence interval {CI}, 135 to 151]) compared with the e-learning group (n = 9; 126 [95% CI, 113 to 138]; mean difference, 17 points [95% CI, 4 to 30]; P < 0.01). No significant effect on the hand-eye score was found (mean difference, 3 points [95 % CI, -3 to 9]; P = 0.32). Ninety-one percent of the virtual reality group wanted more virtual reality learning.Immersive virtual reality learning improved medical students' ultrasound skills significantly compared with e-learning. The hand-eye score was higher in the virtual reality group, although not at a significant level. Students wanted more virtual reality learning. Further research is needed to clarify immersive virtual reality's educational role in the future.

Sleep Deprivation Adversely Impacts Resident Performance for Simulated Arthroscopy

Purpose

The purpose of the study was to assess the performance of residents in orthopaedics before and after a 24-hour shift on a shoulder arthroscopy simulator. The primary study endpoint was an overall performance score (OPS) generated by the simulator.

Methods

A prospective, comparative study of 120 simulator trials by 10 resident junior surgeons was performed in our university hospital’s simulation center between May and November 2018. To avoid memorization bias, all participants performed the same exercise 10 times on a VirtaMed ArthroS simulator prior to the study. Each resident’s performance (the OPS, the operating time, the proportion of procedures with iatrogenic lesions, the camera path length and the hook path length) in two different simulated arthroscopy exercise tasks was assessed once before and once after a 24-hour shift. This sequence was performed three times during the semester, and the change over time in performance was also evaluated.

Results

The OPS was significantly lower after the night shift (P = 0.035 for the first exercise, and P = 0.025 for the second).

Conclusion

In a group of previously trained resident junior surgeons, overall performance with an arthroscopy simulator was significantly worse after a 24-hour shift. The study of secondary parameters of the OPS and the subgroup analysis based on the sleep time and Epworth score vary depending on the type of exercise performed arthroscopically. However, the use of a simulator after a night shift did not prevent the trainee from improving his/her level of performance over time.

Level of Evidence

II, a prospective, comparative study

Effectiveness of virtual and augmented reality for improving knowledge and skills in medical students: protocol for a systematic review

INTRODUCTION

Virtual reality (VR) and augmented reality (AR) technologies are increasingly being used in undergraduate medical education. We aim to evaluate the effectiveness of VR and AR technologies for improving knowledge and skills in medical students.

METHODS AND ANALYSIS

Using Best Evidence in Medical Education (BEME) collaboration guidelines, we will search MEDLINE (via PubMed), Education Resources Information Center, PsycINFO, Web of Knowledge, Embase and the Cochrane Central Register of Controlled Trials for English-language records, from January 1990 to March 2021. Randomised trials that studied the use of VR or AR devices for teaching medical students will be included. Studies that assessed other healthcare professionals, or did not have a comparator group, will be excluded. The primary outcome measures relate to medical students' knowledge and clinical skills. Two reviewers will independently screen studies and assess eligibility based on our prespecified eligibility criteria, and then extract data from each eligible study using a modified BEME coding form. Any disagreements will be resolved by discussion or, if necessary, the involvement of a third reviewer. The BEME Quality Indicators checklist and the Cochrane Risk of Bias Tool will be used to assess the quality of the body of evidence. Where data are of sufficient homogeneity, a meta-analysis using a random-effects model will be conducted. Otherwise, a narrative synthesis approach will be taken and studies will be evaluated based on Kirkpatrick's levels of educational outcomes and the Synthesis Without Meta-analysis guidelines.

ETHICS AND DISSEMINATION

Ethical approval is not required for this systematic review as no primary data are being collected. We will disseminate the findings of this review through scientific conferences and through publication in a peer-reviewed journal.

Upskilling health and care workers with augmented and virtual reality: protocol for a realist review to develop an evidence-informed programme theory

INTRODUCTION

Augmented reality (AR) and virtual reality (VR) are increasingly used to upskill health and care providers, including in surgical, nursing and acute care settings. Many studies have used AR/VR to deliver training, providing mixed evidence on their effectiveness and limited evidence regarding contextual factors that influence effectiveness and implementation. This review will develop, test and refine an evidence-informed programme theory on what facilitates or constrains the implementation of AR or VR programmes in health and care settings and understand how, for whom and to what extent they 'work'.

METHODS AND ANALYSIS

This realist review adheres to the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) standards and will be conducted in three steps: theory elicitation, theory testing and theory refinement. First, a search will identify practitioner, academic and learning and technology adoption theories from databases (MEDLINE, Scopus, CINAHL, Embase, Education Resources Information Center, PsycINFO and Web of Science), practitioner journals, snowballing and grey literature. Information regarding contexts, mechanisms and outcomes will be extracted. A narrative synthesis will determine overlapping configurations and form an initial theory. Second, the theory will be tested using empirical evidence located from the above databases and identified from the first search. Quality will be assessed using the Mixed Methods Appraisal Tool (MMAT), and relevant information will be extracted into a coding sheet. Third, the extracted information will be compared with the initial programme theory, with differences helping to make refinements. Findings will be presented as a narrative summary, and the MMAT will determine our confidence in each configuration.

ETHICS AND DISSEMINATION

Ethics approval is not required. This review will develop an evidence-informed programme theory. The results will inform and support AR/VR interventions from clinical educators, healthcare providers and software developers. Upskilling through AR/VR learning interventions may improve quality of care and promote evidence-based practice and continued learning. Findings will be disseminated through conference presentations and peer-reviewed journal articles.

DICOM 3D viewers, virtual reality or 3D printing - a pilot usability study for assessing the preference of orthopedic surgeons

As standard practice in orthopedic surgery, the information gathered by analyzing Computer Tomography (CT) 2D images is used for patient diagnosis and planning surgery. Lately, these virtual slices are the input for generating 3D virtual models using DICOM viewers, facilitating spatial orientation, and diagnosis. Virtual Reality (VR) and 3D printing (3DP) technologies are also reported for use in anatomy visualization, medical training, and diagnosis. However, it has not been yet investigated whether the surgeons consider that the advantages offered by 3DP and VR outweigh their development efforts. Moreover, no comparative evaluation for understanding surgeon's preference in using these investigation tools has been performed so far. Therefore, in this paper, a pilot usability test was conducted for collecting surgeons' opinions. 3D models of knee, hip and foot were displayed using DICOM 3D viewer, two VR environments and as 3D-printed replicas. These tools adequacy for diagnosis was comparatively assessed in three cases scenarios, the time for completing the diagnosis tasks was recorded and questionnaires filled in. The time for preparing the models for VR and 3DP, the resources needed and the associated costs were presented in order to provide surgeons with the whole context. Results showed a preference in using desktop DICOM viewer with 3D capabilities along with the information provided by Unity-based VR solution for visualizing the virtual model from various angles challenging to analyze on the computer screen. 3D-printed replicas were considered more useful for physically simulating the surgery than for diagnosis. For the VR and 3DP models, the lack of information on bone quality was considered an important drawback. The following order of using the tools was preferred: DICOM viewer, followed by Unity VR and 3DP.

The development of laparoscopic skills using virtual reality simulations: A systematic review

Background

Teaching based on virtual reality simulators in medicine has expanded in recent years due to the limitations of more traditional methods, especially for surgical procedures such as laparoscopy.

Purpose of review

To analyze the effects of using virtual reality simulations on the development of laparoscopic skills in medical students and physicians.

Data sources

The literature screening was done in April 2020 through Medline (PubMed), EMBASE and Database of the National Institute of Health.

Eligibility criteria

Randomized clinical trials that subjected medical students and physicians to training in laparoscopic skills in virtual reality simulators.

Study appraisal

Paired reviewers independently identified 1529 articles and included 7 trials that met the eligibility criteria.

Findings

In all studies, participants that trained in virtual simulators showed improvements in laparoscopic skills, although the articles that also had a physical model training group did not show better performance of one model compared to the other.

Limitations

No article beyond 2015 met the eligibility criteria, and the analyzed simulators have different versions and models, which might impact the results.

Conclusion

Virtual reality simulators are useful educational tools, but do not show proven significant advantages over traditional models. The lack of standardization and a scarcity of articles makes comparative analysis between simulators difficult, requiring more research in the area, according to the model suggested in this review.

Systematic review registration number

Registered by the Prospective Register of Systematic Reviews (PROSPERO), identification code CRD42020176479.

Virtual reality as a learning tool in spinal anatomy and surgical techniques

Background

Surgical simulation is a valuable educational tool for trainees to practice in a safe, standardized, and controlled environment. Interactive feedback-based virtual reality (VR) has recently moved to the forefront of spine surgery training, with most commercial products focusing on instrumentation. There is a paucity of learning tools directed at decompression principles. The purpose of this study was to evaluate the efficacy of VR simulation and its educational role in learning spinal anatomy and decompressive techniques.

Methods

A VR simulation module was created with custom-developed software. Orthopaedic and neurosurgical trainees were prospectively enrolled and interacted with patient-specific 3D models of lumbar spinal stenosis while wearing a headset. A surgical toolkit allowed users to perform surgical decompression, specifically removing soft tissues and bone. The module allowed users to perform various techniques in posterior decompressions and comprehend anatomic areas of stenosis. Pre- and post-module testing, and utility questionnaires were administered to provide both quantitative and qualitative evaluation of the module as a learning device.

Results

28 trainees were enrolled (20-orthopaedic, 8-neurosurgery) in the study. Pre-test scores on anatomic knowledge progressively improved and showed strong positive correlation with year-in-training (Pearson's r = 0.79). Following simulation, the average improvement in post-test scores was 11.4% in junior trainees (PGYI-III), and 1.0% in senior trainees (PGYIII-Fellows). Knowledge improvement approached statistical significance amongst junior trainees (p = 0.0542). 89% of participants found the VR module useful in understanding and learning the pathology of spinal stenosis. 71% found it useful in comprehending decompressive techniques. 96% believed it had utility in preoperative planning with patient-specific models.

Conclusions

Our original VR spinal decompression simulation has shown to be overwhelmingly positively received amongst trainees as both a learning module of patho-anatomy and patient-specific preoperative planning, with particular benefit for junior trainees.

Construct Validity of a Virtual Reality Simulator for Surgical Training in Knee Arthroscopy

Objective Surgical techniques are learned gradually throughout an orthopedic residency. Training on real patients carries drawbacks such as limited access and elevated risk. Alternatively, surgical simulation allows residents to practice in a safe environment with greater access to standardized surgical tasks. Virtual reality simulators display images inside an artificial joint, often providing real-time haptic feedback to allow for realistic interaction. The objective of this study was to evaluate the construct validity of a virtual reality simulator for knee arthroscopy by analyzing the capacity of system parameters to distinguish between expert and novice surgeons. Design This comparative cross-sectional study contrasts the automated performance reports for novice and expert orthopedic surgeons after executing surgical tasks on the ARTHRO Mentor virtual reality simulator. Setting Surgical simulation center at the University of Chile Clinical Hospital, Santiago, Chile. Participants The novice group consisted of 20 second-year orthopedic and traumatology residents at the University of Chile School of Medicine. The expert group consisted of 10 experienced arthroscopic surgeons. All participants carried out standardized tasks in the knee arthroscopy virtual reality simulator. The median performance scores of the two groups were compared, and multivariate logistic regression was performed to assess the capacity of the system to discriminate between the two groups. Results Median performance on the vast majority of surgical tasks was superior for the expert group. The expert group had performance values equal to or higher than the novice group on 43 of the 44 variables recorded for the basic tasks and 74 of the 75 advanced task variables. The multivariate logistic regression analysis discriminated expert from novice users with 100% accuracy. Conclusion The virtual reality simulator for knee arthroscopy showed good construct validity, with performance metrics accurately discriminating between expert and novice users.

A review of participant recruitment transparency for sound validation of hip surgery simulators: a novel umbrella approach

Malposition of implants is associated with complications, higher wear and increased revision rates in total hip replacement (THR) along with surgeon inexperience. Training THR residents to reach expert proficiency is affected by the high cost and resource limitations of traditional training techniques. Research in extended reality (XR) technologies can overcome such barriers. These offer a platform for learning, objective skill-monitoring and, potentially, for automated certification. Prior to their incorporation into curricula however, thorough validation must be undertaken. As validity is heavily dependent on the participants recruited, there is a need to review, scrutinise and define recruitment criteria in the absence of pre-defined standards, for sound simulator validation. A systematic review on PubMed and IEEE databases was conducted. Training simulator validation research in fracture, arthroscopy and arthroplasty relating to the hip was included. 46 validation studies were reviewed. It was observed that there was no uniformity in reporting or recruitment criteria, rendering cross-comparison challenging. This work developed Umbrella categories to help prioritise recruitment, and has formulated a detailed template of fields and guidelines for reporting criteria so that, in future, research may come to a consensus as to recruitment criteria for a hip "expert" or "novice".

Module-Based Arthroscopic Knee Simulator Training Improves Technical Skills in Naive Learners: A Randomized Trial

Purpose

To compare the effectiveness, in comparison to a control group (C), of module-based training (MBT) and traditional learning (TL) as a means of acquiring arthroscopic skills on an arthroscopic surgery simulator.

Methods

Thirty health sciences students with no previous arthroscopy experience were recruited and randomized into 1 of 3 groups: MBT, TL, or C (1:1:1 ratio). Participants in MBT were required to independently practice on a VirtaMed ArthroS simulator (VirtaMed AG, Zurich, Switzerland) for a minimum of 2 hours per week, whereas TL received one-on-one coaching by a senior orthopaedic resident for 15 minutes per week. The control group received no training. All groups were assessed at baseline and at 4 weeks based on objective measures generated by the surgical simulator (procedure time, camera path length, meniscus cutting score, detailed visualization, safety score and total score), and subjective ratings scales (Objective Assessment of Arthroscopic Skill [OAAS] global assessment form, and Competency-Based Assessment form).

Results

Participants in the MBT group trained on average 113 min/week whereas the TL group trained on average 24 min/week. Three-way repeated-measures analysis of variance showed significant group by time interactions for procedure time (P = .006), camera path length (P = .008), safety score (P = .013), total score (P = .003), OAAS form (P < .001), and Competency-Based Assessment form (P < .001). MBT group was superior to C group for procedure time (P = .02), camera path length (P = .003), total score (P = .004), and OAAS form (P = .021), but there were no significant post-hoc differences between MBT and TL groups, or TL and C groups after Bonferroni correction. Total practice time explained 37.5% of the final simulator total score variance.

Conclusions

Knee arthroscopy simulation training with self-learning modules can improve skills in areas such as procedure time, camera path length, and total score in untrained participants compared with a control group.

Clinical Relevance

Module-based simulation training provides additional training time and improves technical skills in naive health science students. It is hoped that this effect can be preserved and applied to junior resident developing in a busy residency program.