December 2002 Bulletin

Virtual reality simulator–on track to reality

By W. Dilworth Cannon, MD and Jay D. Mabrey, MD

The Academy’s "virtual reality" arthroscopic knee surgery simulator project has kicked into high gear. With funding from the National Institutes of Health (NIH) approved this summer, the AAOS and its partner ToLTech are moving full-speed ahead with the project, including testing two key aspects of the simulator during the upcoming 2003 Annual Meeting in New Orleans.

Six years in the making

The promise of virtual reality for orthopaedic education was introduced to more than 900 orthopaedic surgeons at the 1997 Annual Meeting Instructional Course Lectures Dinner. Soon thereafter, the American Board of Orthopaedic Surgery (ABOS) began to investigate this technology and made an investment toward creating a simulator program.

Based on an evaluation of the ABOS effort, and recognizing virtual reality’s potential, the Academy established a Virtual Reality Task Force to study the technology and the requirements for building an arthroscopic simulator. The Arthroscopy Association of North America (AANA) was invited to join in this effort.

$1 million prototype

Our investigation quickly led to the realization that the cost to create a prototype could reach $1,000,000, and there was no guarantee that the prototype would meet expectations. Recognizing the risks, the AAOS Board of Directors, in 1999, approved a Council on Education proposal to invest up to $100,000 toward the design of an educational program for the simulator and validation of the simulator’s efficacy to orthopaedic education.

We had developed the idea. A vision was created. But, we needed a partner. A partner with deep pockets!

Our explorations led us to small and large companies already involved in simulator development for orthopaedics. One company was "bitmapping" the human knee. Another company was testing a simulator, while yet another company was focusing on anatomy, imaging and display. The problem was that all of these companies were concerned with continued funding.

SBIR grants

It was at this point that we learned about the NIH Small Business Innovation Research Granting Program (SBIR). The SBIR Program grants funds to small, start-up technology companies to assist in first generation product development, providing as much as $850,000 to companies in two phases.

Our early investigations included talks with representatives from the University of Colorado Center for Human Simulation (CHS). This group had just completed the NIH Visible Human Dataset Project. To capitalize on this effort, CHS leadership–with University of Colorado assistance–had formed a new start-up company called Touch of Life Technologies (ToLTech). ToLTech wanted to work with us on the project. We had gained a partner with the technical and scientific expertise to create a simulator. They just needed the money to do it!

ToLTech submitted an SBIR Program grant request in 2001, noting a partnership with the Academy. In late June 2002, ToLTech received a positive funding notice from the NIH. Now, with funding in hand, the arthroscopic simulator project is off and running.

An Academy content development group (CDG), formed in 2000, already was at work designing the simulator educational program. This first program will require the learner to complete a diagnostic arthroscopy of the knee and identify pathologies with and without a probe. The learner will have the opportunity to complete several diagnostic procedures and identify different pathologies during each pass through the joint. A hardware-controlled knee joint will enable the learner to manipulate the leg in varus and valgus, as well as extension and flexion. The learner will be evaluated on several criteria including time, thoroughness of the examination, tissue injury, pathology identification, manipulation of the leg and more.

AAOS to perform validation study

The grant request included plans for a validation study to be undertaken by the Academy. This study includes testing in the Orthopaedic Learning Center (OLC) as well as in residency programs. The CDG is developing criteria for residency program selection and study requirements.

The study will include training for residency program attending staff on how to educate residents on diagnostic arthroscopy of the knee, consistent with the simulator program, as well as the creation of a checklist for evaluating resident performance. The AAOS will set the number of simulator trials each resident must complete prior to the first patient encounter. We will then compare simulator performance to the first clinical experience.

The Academy and ToLTech are working on simulator licensing plans once validation is successful. Plans include licensing the simulator to residency programs with hourly usage fee, and placing simulators in the OLC.

Testing at Annual Meeting

At the Annual Meeting in February 2003, the CDG will test two key aspects of the simulator. The first is assessing the graphical display of tissue deformation in the virtual knee as it is flexed, both in varus and valgus, in response to the manipulation of the mechanical knee. The second aspect to be tested is the ability of the haptic display to generate the feel of an instrument sliding along tissue, including the display of cartilage damage resulting from excess force. The CDG is inviting between 40 and 50 Academy members who have served as faculty at AAOS and AANA OLC courses to assist in this testing effort.

W. Dilworth Cannon, MD, is chair of the Virtual Reality Content Development Group. Jay D. Mabrey, MD, is chair of the Virtual Reality Task Force.

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