October 1999 Bulletin

Surgical VR gets real

'The surgeon . . .needs to feel he's in there working on the knee as if it was the real thing.'

Academy explores new technology use for education

By Carolyn Rogers

Less than 10 years ago, dropping the phrase "virtual reality" into casual conversation would have produced a blank stare from most listeners. In 1999, virtual reality is a reality, and most people recognize the term.

Still, the practical applications of this technology are not widely known; most people have a vague notion that it involves computers and ultra-realistic video games. The truth is that virtual reality is now being utilized by NASA, the armed forces, the education industry, the health care industry and yes, the video game and entertainment industry.

Although the technology is still developing, it's already being used for such diverse applications as car repair, architectural and mechanical design, scientific visualization and even for driving rovers on Mars.

Virtual reality is proving to be an ideal tool for education because it enables its users to be exposed to an experience that might normally be too dangerous or expensive to learn in the real world. The technology has been used by the Air Force to train pilots, and by NASA to train astronauts, allowing them to prepare for emergency situations in advance.

In the same way, surgeons are using virtual reality technology to advance their discipline, and to assist in surgical training. VR technology has already been utilized to enable computerized robots to perform open-heart surgeries and to assist surgeons in performing total hip replacements. The more common use of virtual reality by surgeons, however, remains in surgical training.

Virtual reality can be superior to current methods of surgical teaching in the following ways, according to Karl Reinig, PhD, of the University of Colorado's Center for Human Simulation:

The technology has to be advanced and sufficiently "real" if a surgical virtual reality simulator is to be successful in actual practice, Reinig stresses.

"The surgeon has to basically forget about the computer aspects; he needs to feel that he's in there working on the knee as if it was the real thing," Reining says. "The further you get away from that ideal, the more the doctor will want to go get a cadaver and work on that instead."

An initial 1996 investigation by the Academy into the possibility of developing a virtual reality simulator for surgical training determined that the technology was too new, unproven and expensive at that point to make a commitment to such a project.

In fall of 1997, the American Board of Orthopaedic Surgery (ABOS) took the lead in simulator development for orthopaedics, setting a goal of testing candidates for certification on their surgical skills, especially arthroscopy. The board has been concerned for some time that there is no effective way to evaluate skills proficiency for certifying and recertifying exams, according to Robert Poss, MD, a member of the ABOS board of directors. As the technology developed, they became increasingly interested in developing a virtual reality arthroscopic knee simulator (VR-AKS) for testing purposes.

"We knew this effort would have to be one of the entire orthopaedic community," Dr. Poss says. "Before a simulator could be used as a testing tool, it would first have to be used as an educational and training tool."

So the ABOS introduced the simulator concept to the Academy through a prototype developed by Boston Dynamics, Cambridge, Mass. The Council on Education immediately established the Task Force on Virtual Reality to investigate current VR technologies and to recommend appropriate Academy involvement in VR development and its use in educational programs. The Academy's VR task force is chaired by Jay D. Mabrey, MD.

The ABOS continues to be vitally
interested in the development of the VR-AKS, Dr. Poss says, but "the Academy has the ball now because of the enormity of the project."

Why an arthroscopic simulator? "Arthroscopic surgery lends itself to virtual reality simulation more so than most other orthopaedic procedures because of its restricted field of view and the limited physical interaction between the physician and patient," says Dr. Mabrey. "Unlike other procedures, such as tendon repair and basic fracture fixation, there is little, if any, crossover in technique from other procedures. And the most realistic training models available are cadaveric knees, which are both expensive and difficult to use for more than two days of training. There's also no guaranteed uniformity among these specimens and it's difficult to reproduce realistic and consistent pathologies in these knees."

Thus, successful and timely completion of an arthroscopic knee procedure is now almost entirely dependent upon the surgeon's experience with earlier clinical procedures involving real patients in a real operating room, Dr. Mabrey says.

The task force recently conducted a market research study to develop more insight into resident education in arthroscopic surgery, and to explore perceptions of-and interest in-the use of virtual reality simulation for resident ar- throscopic training. In-depth telephone interviews were conducted with 11 Academy members-eight orthopaedic department chairs and three staff members involved in resident education.

In terms of resident education programs, some of the study's findings include:

When questioned about the development of a virtual reality arthroscopic simulator:

In addition to the Boston Dynamics prototype, the task force has examined several arthroscopic simulator prototypes in existence in the United States and United Kingdom. "We felt that we needed better force feedback and higher resolution images," Dr. Mabrey says. "We didn't see that in any of these other prototypes."

The task force met in October 1998 and reviewed technology development at three companies-Boston Dynamics, Mitsubishi, and the University of Colorado's Center for Human Simulation.

"It will take about 18 months to develop a truly useful simulator," Dr. Mabrey says. "The hardware is there. We have the forced feedback devices which let you feel what you're doing and are also the most expensive parts. The computers and desktop work stations are actually becoming very inexpensive, and a surrogate knee, which is sort of a physical representation of the knee that you manipulate, is also available."

A two-stage developmental effort is planned for the VR-AKS project. In the initial phase, a simulator would be created that would train the user to complete a thorough arthroscopic examination of the knee joint. If the first phase is deemed successful by validation study, the project will proceed to the second stage-development of software that would enable learners to complete surgical procedures for different knee pathologies.

This is an expensive venture; the development of the VR-AKS is estimated to be at least $1 million.

The Academy's plan is to find an entrepreneurial company interested in investing up to $1 million in the development of this project. The company should also commit to the ongoing marketing, sales, service and support of any resulting product. The Academy will invest up to $100,000 to support two aspects of the project:

  1. Content development. The Academy will support the costs of bringing together a team of orthopaedic surgeons and biomechanical engineers to provide content development and subject matter expertise.
  2. Validation study. The Academy will conduct a thorough study to validate the educational efficacy and accuracy of the resulting prototype.

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