October 2003 Bulletin

Virtual reality project continues to make progress

By Howard Mevis

The Academy and our development partner Touch of Life Technologies (ToLTech) are making progress toward introducing a virtual reality arthroscopic knee surgery simulator for an extensive set of tests with orthopaedic surgeons and residents in 2004. The simulator program, comprised of an educational program, orientation, training and testing software, surrogate leg model, instruments, video display of realistic knee anatomy, and associated computer hardware will undergo a validation study beginning approximately July 2004.

The project’s Content Development Group (CDG), led by Dilworth Cannon, MD, is nearing completion of the phase I educational program for the virtual reality simulator. This program will include a lecture and handout on the diagnostic sweep of the knee, developed by Robert Hunter, MD, and a video demonstration created by Howard Sweeney, MD. “One of the most significant debates we had regarding the lecture and video focused on the different approaches to complete a diagnostic sweep of the knee joint. After considerable discussion, we agreed to adopt ‘a generic method’ for completing the sweep. It would not be educationally sound to demonstrate multiple methods, nor try to combine different approaches,” Dr. Cannon reported. Self-assessment examination questions need to be written to complete the educational portion of the simulator program.


Scott Gillogly,MD, from the VR Task Force
and Karl Reinig, PhD, ToLTech, test
haptic response using a probe against
landmarks in the knee joint

Three modules

The simulator incorporates three modules. The first provides the learner with an orientation to using the simulator. “This is a new experience for everyone, and we want to make sure that anyone using the simulator is well oriented to the technology,” according to Dr. Cannon. Once the learner has a point of reference, training begins.

Each training module includes just-in-time “lessons” for immediate feedback and review while completing various aspects of the diagnostic sweep of the knee. For example, examining the medial compartment requires valgus force applied to the knee at 20° to 30° flexion. If improper angulation or insufficient force is applied during a training session, the simulator program will provide immediate feedback through text and visual review of the correct technique.


High-resolution display of knee joint flexed
at 30 demonstrates the quality of image reproduction
from the sumulator program.

Rating checklist

With the lecture and video completed, the CDG is developing a rating checklist to be used by the simulator and orthopaedic surgeons evaluating the performance of a resident or orthopaedic surgeon in completing a diagnostic sweep of the knee. Dr. Cannon and William Garrett Jr., MD, PhD, developed the initial checklist.

“The checklist is consistent with the lecture/handout and video,” Dr. Cannon said. “We had to break down each activity into component parts. For example, rather than scoring just on examining the medial meniscus, the checklist includes seven different actions involved in inspecting the meniscus and articular cartilage in the medial compartment visually and with a probe.”

The CDG is testing the checklist using video recordings of diagnostic examinations completed by residents, fellows and orthopaedic surgeons in practice. “We need to ensure there is inter-rater reliability in using the checklist prior to commencing the simulator validation study,” Dr. Cannon indicated.

The simulator has several component parts including an actual leg model that can be manipulated in varus, valgus, extension and flexion. Instruments are introduced through established portals. The reproduction of knee anatomy is designed to provide the learner with the most realistic environment possible. “We are nearing completion of a very realistic true anatomic depiction of the inside of the knee based on 0.10 mm sectioning of a human knee,” Dr. Cannon reported.

Validation study

The validation study, planned to commence July 1, 2004, will involve educating, training and testing a group of residents and orthopaedic surgeons. The CDG plans to release a Call for Participation in October 2003. The validation study premise states:

  1. Residents using a virtual reality arthroscopic knee surgery simulator to learn and practice the techniques of diagnostic arthroscopy of the knee will then complete the procedure on an actual patient:

    [The validation study includes control and test groups with about 20 residents in each group.]

  2. Orthopaedic surgeons using a virtual reality arthroscopic knee surgery simulator will reduce examination time and complete a more thorough examination of patients.

Impact of simulation training

The Academy’s goal is to see a virtual reality arthroscopic knee simulator in every resident training program in the country. A study out of Yale University1 showed that residents trained with a virtual reality surgical simulator performed laparoscopic cholecystectomy faster and with significantly less tissue damage than residents who did not train on the simulator. Surgical errors are thus reduced.

The additional costs of training interns and residents in the operating room aso can be reduced. Bridges and Diamond2 reported that approximately $48,000 in extra operating room time is spent training residents in surgical techniques over a four-year period.

It is not a matter of whether virtual reality surgical simulators will be an integral part of every resident training program, but when.

Howard Mevis is director, electronic media, evaluation and course operations. He can be reached at mevis@aaos.org

  1. Seymour NE, Gallagher AG, Roman SA, et al: Virtual reality training improves operating room performance: results of a randomized, double-blinded study. Annals of Surgery, 2002. 236(4): 458-463.

  2. Bridges M, & Diamond DL: The financial impact of teaching surgical residents in the operating room. American Journal of Surgery, 1999. 177(1): p. 28-32.


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