Surgery Training and Simulation Using Virtual and Augmented Reality for Knee Arthroplasty

Robotic arthroplasty software training improves understanding of total knee arthroplasty alignment and balancing principles: a randomized controlled trial

Understanding alignment and gap balancing in Total Knee Arthroplasty (TKA) can be challenging for trainee and experienced orthopedic surgeons. Traditional learning methods may not effectively translate to real-life scenarios. The advent of advanced technologies like robotic surgery and navigation systems has revolutionized intraoperative understanding of gap balancing techniques. This trial aims to investigate the effectiveness of robotic TKA planning software in educating trainees about alignment and ligament balancing. We hypothesize that a single session with the software will significantly enhance trainees' understanding of these techniques. This UK-based single-center, two-arm, group parallel randomized controlled trial was conducted during a national robotic arthroplasty symposium. It aims to evaluate the effect of robotic knee arthroplasty software training on understanding TKA alignment and gap balancing principles using Multiple Choice Questions (MCQs). The MCQ test was crafted based on established guidelines from a different institution with expert consensus in the field. Our study revealed that baseline knowledge of gap balancing and alignment principles was generally low among all participants. However, the intervention group, which received comprehensive robotic software training, demonstrated a significant improvement in their MCQ scores compared to the control group, which did not undergo the training. In conclusion, our study demonstrates that robotic arthroplasty software training significantly improves the understanding of TKA alignment and balancing principles among orthopedic trainees. Level of Evidence II.

Single-center experience with Knee+™ augmented reality navigation system in primary total knee arthroplasty

BACKGROUND

Computer-assisted systems obtained an increased interest in orthopaedic surgery over the last years, as they enhance precision compared to conventional hardware. The expansion of computer assistance is evolving with the employment of augmented reality. Yet, the accuracy of augmented reality navigation systems has not been determined.

AIM

To examine the accuracy of component alignment and restoration of the affected limb's mechanical axis in primary total knee arthroplasty (TKA), utilizing an augmented reality navigation system and to assess whether such systems are conspicuously fruitful for an accomplished knee surgeon.

METHODS

From May 2021 to December 2021, 30 patients, 25 women and five men, underwent a primary unilateral TKA. Revision cases were excluded. A preoperative radiographic procedure was performed to evaluate the limb's axial alignment. All patients were operated on by the same team, without a tourniquet, utilizing three distinct prostheses with the assistance of the Knee+™ augmented reality navigation system in every operation. Postoperatively, the same radiographic exam protocol was executed to evaluate the implants' position, orientation and coronal plane alignment. We recorded measurements in 3 stages regarding femoral varus and flexion, tibial varus and posterior slope. Firstly, the expected values from the Augmented Reality system were documented. Then we calculated the same values after each cut and finally, the same measurements were recorded radiologically after the operations. Concerning statistical analysis, Lin's concordance correlation coefficient was estimated, while Wilcoxon Signed Rank Test was performed when needed.

RESULTS

A statistically significant difference was observed regarding mean expected values and radiographic measurements for femoral flexion measurements only (Z score = 2.67, P value = 0.01). Nonetheless, this difference was statistically significantly lower than 1 degree (Z score = -4.21, P value < 0.01). In terms of discrepancies in the calculations of expected values and controlled measurements, a statistically significant difference between tibial varus values was detected (Z score = -2.33, P value = 0.02), which was also statistically significantly lower than 1 degree (Z score = -4.99, P value < 0.01).

CONCLUSION

The results indicate satisfactory postoperative coronal alignment without outliers across all three different implants utilized. Augmented reality navigation systems can bolster orthopaedic surgeons' accuracy in achieving precise axial alignment. However, further research is required to further evaluate their efficacy and potential.

Mixed Reality and Artificial Intelligence: A Holistic Approach to Multimodal Visualization and Extended Interaction in Knee Osteotomy

OBJECTIVE

Recent advancements in augmented reality led to planning and navigation systems for orthopedic surgery. However little is known about mixed reality (MR) in orthopedics. Furthermore, artificial intelligence (AI) has the potential to boost the capabilities of MR by enabling automation and personalization. The purpose of this work is to assess Holoknee prototype, based on AI and MR for multimodal data visualization and surgical planning in knee osteotomy, developed to run on the HoloLens 2 headset.

METHODS

Two preclinical test sessions were performed with 11 participants (eight surgeons, two residents, and one medical student) executing three times six tasks, corresponding to a number of holographic data interactions and preoperative planning steps. At the end of each session, participants answered a questionnaire on user perception and usability.

RESULTS

During the second trial, the participants were faster in all tasks than in the first one, while in the third one, the time of execution decreased only for two tasks ("Patient selection" and "Scrolling through radiograph") with respect to the second attempt, but without statistically significant difference (respectively [Formula: see text] = 0.14 and [Formula: see text] = 0.13, [Formula: see text]). All subjects strongly agreed that MR can be used effectively for surgical training, whereas 10 (90.9%) strongly agreed that it can be used effectively for preoperative planning. Six (54.5%) agreed and two of them (18.2%) strongly agreed that it can be used effectively for intraoperative guidance.

DISCUSSION/CONCLUSION

In this work, we presented Holoknee, the first holistic application of AI and MR for surgical planning for knee osteotomy. It reported promising results on its potential translation to surgical training, preoperative planning, and surgical guidance. Clinical and Translational Impact Statement - Holoknee can be helpful to support surgeons in the preoperative planning of knee osteotomy. It has the potential to impact positively the training of the future generation of residents and aid surgeons in the intraoperative stage.

A Comparative Study of Traditional Technique Guide versus Virtual Reality in Orthopedic Trauma Training

Background

Medical and surgical education is an expansive field fraught with many challenges. Technology such as virtual reality could be a new venue that can offer a solution to improve surgical training.

Objective

The objective of this prospective, blinded study was to evaluate virtual reality as a training model for orthopedic surgery and surgical training at large.

Methods

Fourth-year medical students with novice skills volunteered to participate in this observer-blinded 1:1 randomized controlled trial. They had no prior experience in tibia intramedullary nail (IMN) surgery. They were randomized into traditional technique guide education and virtual reality. The participants were timed on their mock surgery, and a blinded observer was utilized to subjectively grade their performance throughout the procedure using the Global Assessment 5-point Rating Scale and Procedure-Specific Checklist.

Results

Thirty-eight participants were recruited and randomized into virtual reality (19) and traditional (19) groups. There were trends in all categories favoring the virtual reality group. The VR group had improved time to completion (9.6 minutes vs 12.2 minutes, P = 0.034) and reduced need for corrections within the mock procedure (2.2 vs 2.5; P = 0.05).

Conclusion

Virtual reality training was more effective than traditional training in learning and completing the steps of the tibia IMN surgery for novice medical students. Virtual reality training may be a useful method to augment orthopedic education and surgical training.

Exploring the Role of Simulation Training in Improving Surgical Skills Among Residents: A Narrative Review

The role of simulation in medical education is crucial to the development of surgeons' skills. Surgical simulation can be used to improve surgical skills in a secure and risk-free environment. Animal models, simulated patients, virtual reality, and mannequins are some types of surgical simulation. As a result, feedback encourages students to reflect on their strengths and weaknesses, enabling them to focus on improvement. Healthcare simulation is a strong educational instrument, and the main goal of this is to give the students an opportunity to do a practical application of what they have learned through theory. Before taking it to the patients, they will already have certain tools they have previously acquired during the practice. This makes it easier for students to identify the knowledge gaps that they must fill to improve patient outcomes. Moreover, simulation brings a wonderful opportunity for students to acquire skills, gain confidence, and experience success before working with real patients, especially when their clinical exposure is limited. The use of simulation to teach technical skills to surgical trainees has become more prevalent. The cost of setting up a simulation lab ranges from $100,000 to $300,000. There are several ways to evaluate the effectiveness of simulation-based surgical training. Repetitive surgical simulation training can improve speed and fluidity in general surgical skills in comparison to conventional training. Few previous studies compared learners who received structured simulation training to a group of trainees who did not receive any simulation training in single-center randomized control research. Significantly faster and less time-consuming skill proficiency was noticeable in simulated trainees. Despite being anxious in the operating room for the first time, simulated trainees completed the surgery on time, demonstrating the effectiveness of surgical simulation training. Traditional surgical training involves senior-surgeon supervision in the operating room. In simulation-based training, the trainees have full control over clinical scenarios and settings; however, guidance and assessment are also crucial. Simulators allow users to practice tasks under conditions resembling real-life scenarios. Simulators can be compared with traditional surgical training methods for different reasons. For example, intraoperative bleeding may occasionally show up not only visibly on the screen but also by shaking the trocars erratically. Without haptics, training on virtual simulators can cause one's pulling and pushing forces, which are frequently greater than what the tissue needs, to be distorted. A good method of simulation training is using virtual reality simulators with haptics and simulated patients. The availability of these facilities is limited, though, and a typical session might include an exercise involving stacking sugar cubes and box trainers. The degree of expertise or competency is one area that needs clarification as medical education transitions to a competency-based paradigm. The article aims to provide an overview of simulation, methods of simulation training, and the key role and importance of surgical simulation in improving skills in surgical residents.

Consequences of COVID-19 Pandemic on Orthopedic Residents' Clinical and Academic Performance, and the Subsequent Impact on Their Mental Status in Saudi Arabia

INTRODUCTION

Impact of COVID-19 pandemic on the orthopedic residency programs was substantial worldwide. Orthopedic residency programs eventually survived such a hardship with implementation of certain measures. The impact of COVID-19 pandemic on the orthopedic trainees was variable relative to the country in which orthopedic residency program is based. This study aimed to assess the experience of the orthopedic residents during COVID-19 pandemic in Saudi Arabia and consequences on mental health, academic performance, and clinical training.

METHODS

A cross-sectional study was conducted from June 2021 to August 2021. An online survey was sent to the orthopedic residents in Saudi Arabia. The questionnaire was arranged into four sections pertaining to demographic data, academic activity, mental health, and clinical activity.

RESULTS

One-hundred forty-four orthopedic residents participated with mean age of 28.7 ± 5.67 years. Males were 108 (75%) and females were 36 (25%). Fifty-four (37.5%) residents worked in COVID-19 isolation unit. One-hundred twenty residents (83.3%) treated COVID-19 patients. Thirty residents (20.8%) had positive COVID-19 tests. Eighty-four (58.3%) residents were quarantined. Overall online education was difficult (41%). Half of the participants faced online difficulties in technicality, maintaining attention, and interaction with audience and examiners. Prospective research conduction was difficult (71.4%). More than 50% of residents experienced difficulties with isolation, quarantine, socialization, and anxiety of disease transmission. Physical examination was difficult for 50% of trainees. No shortage of PPE supply was reported. Getting hands-on surgical training was very difficult (47.8%).

CONCLUSION

COVID-19 pandemic had an adverse impact on Saudi orthopedic residents in terms of academic performance, mental wellbeing, and clinical training. After all, adequate level of orthopedic training quality was maintained. In crises, collaborative efforts are needed to minimize undesirable consequences on the trainees' competency level. Residency program decision makers should utilize all available strategies to optimize the training environment to achieve the required competency level.