Supporting modern theories of learning, virtual reality serves as an adjunct to, or replacement for, traditional teaching. While more research needs to be done to correlate this new method of learning to real-world mastery, the data so far is very promising.

The evolution of surgical education and training

 The Evolution of Virtual Reality in Shoulder and Elbow Surgery

Lohre R., Athwal GS, Warner JP, Goel D.P. The Evolution of Virtual Reality in Shoulder and Elbow Surgery. 2020. Journal of Shoulder and Elbow Surgery International. 2020, 4(2): 215-223

The use of virtual reality (VR) in shoulder and elbow surgery has varying levels of evidence, from I to IV, and typically involves educational randomized controlled trials. However, the terms and definitions used in the literature are often redundant, confusing, or outdated. The purpose of this review was to characterize previous uses of VR in shoulder and elbow surgery in preoperative, intraoperative, and educational domains including trauma and elective surgery.

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Effectiveness of Immersive Virtual Reality on Orthopedic Surgical Skills and Knowledge Acquisition Among Senior Surgical Residents

Lohre R, Bois A, Athwal GS, Lapner P, Pollock J, Goel DP. Effectiveness of Immersive Virtual Reality on Orthopedic Surgical Skills and Knowledge Acquisition Among Senior Surgical Residents: A Randomized Clinical Trial JAMA Network Open. 2020, 3(12):e2031217

Immersive virtual reality (iVR) simulators are of increasing interest for surgical training. The training effectiveness of iVR compared with video training in complex skill acquisition was studied using a randomized, intervention-controlled clinical trial that included senior orthopedic surgery residents from multiple institutions in Canada during a single training course. Surgical training with iVR demonstrated superior learning efficiency, knowledge, and skill transfer.

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Immersive Virtual Reality: A Paradigm Shift in Education and Training

Ryan Lohre, MD and Danny P. Goel, MD, MSC, FRCSC, AAOS Now, “Immersive Virtual Reality: A Paradigm Shift in Education and Training”, January 2020.

The training of both aspiring and established surgeons remains rooted in the historic model of mentorship coupled with direct learning on patients. Yet, beyond the classic Halstedian “see one, do one, teach one” method of learning, there are other well-researched learning methods that virtual reality supports. Applying computing power and modern, highly realistic graphics creates an immersive operating environment that affords repetition of procedures with infinite variability. Trainees test their skills, make mistakes, accept feedback, reflect, and then repeat until they achieve proficiency. This has the potential for more rapid and efficient learning gained through greater experience, creating an accelerated path to mastery.

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Virtual Reality in Spinal Endoscopy: a Paradigm Shift in Education to Support Spine Surgeons

Ryan Lohre, Jeffrey C. Wang, Kai-Uwe Lewandrowski, Danny P. Goel, J Spine Surg, “Virtual reality in spinal endoscopy: a paradigm shift in education to support spine surgeons,” January 2020

With technological advances in computer processing, the state of virtual reality simulation for training in neurosurgery and orthopedic surgery continues to improve. Its use has been endorsed by medical societies and organizations, and there is a growing body of support in the medical literature. A systematic review encompassed 38 separate studies that illustrate use of virtual reality, augmented reality and mixed-reality across a wide range of procedures. The studies found improvement in both technical skills and patient outcomes in short term follow-up.

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Improved Complex Skill Acquisition by Immersive Virtual Reality

Lohre R., Bois A., Athwal G.S., Goel D.P. CSES. Improved Complex Skill Acquisition by Immersive Virtual Reality: A Randomized Controlled Trial. J Bone Joint Surg Am. 2020, 102(6):e26

The purpose of this multicenter, blinded, randomized controlled trial was to determine the validity and efficacy of immersive virtual reality (iVR) training in orthopaedic resident education. The focus was on achieving optimal glenoid exposure. IVR demonstrated substantially improved translational technical and nontechnical skills acquisition over traditional learning. Additionally, the results demonstrate the face, content, construct and transfer validity for iVR.

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Competency-based surgical training

A pilot study to evaluate the face & construct validity of an orthopaedic virtual reality simulator

Feeley A, Feeley I, Merghani K, Sheehan E. A pilot study to evaluate the face & construct validity of an orthopaedic virtual reality simulator. Injury. 2021 Jul;52(7):1715-1720. doi: 10.1016/j.injury.2021.04.045. Epub 2021 Apr 16. PMID: 33926708.

This study aimed to identify the face and construct validity of the PrecisionOS trauma module proximal femoral nail procedure. Participants carried out a simulated proximal femoral nail on the POST immersive virtual platform following instruction on its use. The results demonstrated a statistically significant difference across all group’s novel performance, concluding the proximal femoral nail module on the PrecisionOS platform demonstrated good face and construct validity.

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Immersive Virtual Reality in Endoscopic and Open Spine Surgical Training

Lohre R, Kim, L, Wang, J and Goel DP. Immersive Virtual Reality in Endoscopic and Open Spine Surgical Training. Technical Advances in Minimally Invasive Spine Surgery, Navigation, Robotics and Augmented and Virtual Reality. Springer Nature. (in press)

Simulation in surgical education provides trainees with opportunity to acquire or retain skill. Skill in spine surgery may be defined as technical or non-technical – procedural knowledge and understanding. Research into effectiveness of simulator training shows that initial and incremental improvements eventually plateau. The ability of the simulator to provide efficient and effective training correlative to real world experiences defines the simulator’s transfer effectiveness of skills.

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Eight-year Outcomes of a Competency-Based Residency Training Program in Orthopedic Surgery

Markku T. Nousiainen, Polina Mironova, Melissa Hynes, Susan Glover Takahashi, Richard Reznick, William Kraemer, Benjamin Alman, Peter Ferguson & The CBC Planning Committee (2018) Eight-year outcomes of a competency-based residency training program in orthopedic surgery, Medical Teacher, 40:10, 1042-1054, DOI: 10.1080/0142159X.2017.1421751

The use of simulation in training was a core element of a pilot residency training program begun in 2009 by the Division of Orthopaedic Surgery at the University of Toronto. It investigated the efficacy of a competency-based curriculum (CBC) for a subset of residents, compared to a strictly time-based approach. The modularized approach dramatically intensified the structured learning elements and assessment process. Eight of the 14 residents who participated completed their residency training in four years rather than the traditional five.As a result, the Division of Orthopaedic surgery made the decision to fully adopt the CBC as the sole mode of training and assessment in the residency training program in the 2013–14 academic year. That same year, the Royal College of Physicians and Surgeons of Canada mandated that all postgraduate specialty programs in Canada were to adopt a competency-based framework by the year 2022.

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Effectiveness of training with VR

Surgical Device Representatives Preference for Experiential Learning via Immersive Virtual Reality

Lohre R, Goel DP. Surgical Device Representatives Preference for Experiential Learning via Immersive Virtual Reality. Journal of Orthopaedic Experience and Innovation. 2022

Immersive VR training is able to assess and track SDR learner performance and is valued by SDRs greater than traditional training formats. The cost of incorporating this technology is 2.8x less than current didactic and in-person learning formats. This is the first study of its kind to assess the use of IVR in the SDR population.

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Novel Application of Immersive Virtual Reality Simulation Training

Lohre R, Goel DP, Leveille L. Novel Application of Immersive Virtual Reality Simulation Training: A Case Report. JAAOS Global Research and Reviews. JAAOS Global Research and Reviews. 2021, 5(11):e21.00114

There is increasing evidence for the use of immersive virtual reality (iVR) in orthopaedic education. Several randomized controlled trials demonstrate improved trainee performance relative to control when measured in analogous operating room assessments. This is the first case report demonstrating direct patient care after the use of iVR. The implications of cost-effectiveness through skill transfer and patient safety are highlighted.

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Mitigating Surgical Skill Decay in Orthopedics Using Virtual Simulation Learning

Lohre R, Warner JP, Morrey B, Athwal GS, Morrey M, Mazzocca A. Mitigating Surgical Skill Decay in Orthopedics Using Virtual Simulation Learning JAAOS Global Research and Reviews. 2021, 5(10):e21.00193

The COVID-19 pandemic has interrupted orthopaedic training structures. Orthopaedic surgical skill decay can occur in days to months, depending on the initial skill level. Researchers determined skill decay mitigation strategies should use best available evidence technologies and course structures that satisfy advanced learning concepts. The virtual curriculum, including immersive virtual reality (iVR) simulators, could provide cost-effective solutions to training.

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Real Learning in a Virtual World: How VR Can Improve Learning and Training Outcomes

Deliotte Insights, Real learning in a virtual world: How VR can improve learning and training outcomes, 2018.

Those tasked with training individuals to perform in high-risk environments face a conundrum: How can they deliver the benefits of learning from experience without the costs and dangers of putting trainees in those experiences? The answer is to recreate them using virtual reality (VR). VR presents immersive, realistic situations over and over again, building the expertise to deal with those situations before facing them in the real world. Research has shown that virtual reality reduces the time to learn while increasing the amount learned, while also improving long-term knowledge retention. In scenarios from food processing to handing dangerous industrial gases, VR is proven to promote better and faster learning. But where it truly comes into a class of its own apart from other training methods is when the body of knowledge to attain is complex.

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The value of VR surgical training

Immersive Technologies Offer Short and Long-Term Value

Lohre R, Morrey B, Goel DP. Immersive Technologies Offer Short and Long-Term Value. AAOS NOW. 2020

The global orthopaedic community has seen profound changes in training and practice with the restrictions imposed during the COVID-19 pandemic. Surgical volume, practice management, and healthcare economics will see continued downstream effects, and travel restrictions have prevented surgeons from attending courses and conferences. This study reviews the impact to carbon emissions with utility of virtual reality while delivering meaningful education and remote mentorship.

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A Portable Hip Arthroscopy Simulator Demonstrates Good Face and Content Validity with Incomplete Construct Validity

Feeley A, Turley L, Sheehan E, Merghani K. A Portable Hip Arthroscopy Simulator Demonstrates Good Face and Content Validity with Incomplete Construct Validity. Arthrosc Sports Med Rehabil. 2021 Jul 17;3(5):e1287-e1293. doi: 10.1016/j.asmr.2021.05.009. PMID: 34712965; PMCID: PMC8527255.

The purpose of this study was to evaluate the face, content and construct validity of a portable hip arthroscopy module in a regional orthopaedic unit. The study concluded this hip arthroscopy simulator demonstrated acceptable face and content validity. Participants reported high levels of satisfaction with the module. Additionally, the study is clinically relevant because it demonstrates good face and content validity. The addition of haptic feedback in a hip arthroscopy simulator may improve learning.

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Virtual and Augmented Reality for Surgical Training and Simulation in Knee Arthroplasty.

Lohre R, Goh G, Parvizi J, Goel DP. Virtual and Augmented Reality for Surgical Training and Simulation in Knee Arthroplasty. Archives of Orthopaedic and Trauma Surgery (AOTS), 2021. 141(12):2303-2312

This article examines the role of immersive virtual reality (iVR), augumented reality and mixed reality technologies in knee arthroplasty. This spectrum of extended reality technology integration enables surgeons to visualize patient-specific anatomy, enhance preoperative planning and provide intraoperative guidance. The authors concluded that extended reality technologies have a myriad of potential applications in orthopaedic surgery.

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Immersive Virtual Reality Provides Value to Orthopaedic Surgical Training Programs

Goel, DP and Lohre, R. Immersive Virtual Reality Provides Value to Orthopaedic Surgical Training Programs. Health Management Policy and Innovation

Immersive virtual reality (IVR) is a disruptive innovation that may significantly improve the quality of surgical training while lowering costs for such education. The evidence for IVR thus far shows that compared to traditional bioskills training, IVR demonstrates a greater effect on skill improvement for surgical trainees at a lower cost. The inherent realism of the IVR experience may partly substitute for operating room training, thus reducing the opportunity costs for training programs.

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The Use of Immersive Virtual Reality (IVR) in Pediatric Orthopaedic Education

Lohre, R., Verhofste, B., Hedequist, D., Jacobson, J., & Goel, D. (2022). The Use of Immersive Virtual Reality (IVR) in Pediatric Orthopaedic Education. JPOSNA®4(S1). 

The traditional postgraduate surgical master-apprenticeship education model is undergoing a significant paradigm shift. For the past century, the transition from trainee to orthopaedic surgeon has been accomplished through stepwise integration of theoretical knowledge, observation of senior faculty, basic surgical skill acquisition, and gradual autonomy in complex procedures. Over the past decade, the explosion of virtual reality has heightened interest in this field for surgical residency training. The core principle of simulation training is “learning by doing” for acquisition and retention of surgical skills. It allows trainees to integrate theoretical knowledge with procedural skills in a risk-free setting prior to application in the operating room. Significant data supports the use of surgical simulation and virtual reality training modalities for skill acquisition in nearly every surgical specialty. The advancement in technology will allow immersive reality to become a standard educational platform in the future and this article provides a basic framework for understanding this ever-changing field.

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Pending Publication

Error in Implant Orientation for Novice Versus Expert Surgeons

Lohre R, Bois A, Lapner P, Pollock J, Athwal GS, Goel DP. Error in Implant Orientation for Novice Versus Expert Surgeons: The Positive Impact of Hands-On Learning. JSES (submitted)

Glenoid baseplate orientation in reverse shoulder arthroplasty (RSA) influences clinical outcomes, complications, and failure rates. Novel technologies have been produced to decrease performance heterogeneity of low and high-volume surgeons. This study aimed to determine novice and experienced shoulder surgeon’s ability to accurately characterise glenoid component orientation in an intra-operative scenario. This paper highlights the importance of hands-on learning and skill transfer with implant orientation.

How Immersive Virtual Reality is Changing Hip Arthroscopy Education

Lohre R, Goel DP. How Immersive Virtual Reality is Changing Hip Arthroscopy Education. – (submitted)

Hip arthroscopy for treatment of altered hip morphology contributing to femoroacetabular impingement syndrome (FAI) has been shown in a large randomized trial as beneficial, and superior to conservative management.  Common complications are significant for low volume surgeons.  In 2018, Mehta et al. examined complication and reoperation rates of varying surgical experience to determine learning curves. They determined that hip arthroscopy is particularly, and unexpectedly demanding, with total surgical volumes of >519 cases producing the lowest rate of reoperation, at 2.6. We propose the addition of contemporary, immersive virtual reality (iVR) simulator education as a means for both novice and expert surgeons to learn the complex task of hip arthroscopy.

Improvement in Translational and Nontechnical Skills with VR

Pending Publication

A recent study investigated the validity and efficacy of immersive virtual reality training for orthopaedic resident education, via a multicenter, blinded, randomized controlled trial. A resident group of 10 senior orthopaedic residents and an expert group of fellowship-trained and experienced shoulder arthroplasty surgeons participated. The study compared immersive VR with traditional learning (via a technical journal article), using glenoid exposure as the test procedure. Training effectiveness was determined by Objective Structured Assessment of Surgical Skills (OSATS) scores, a laboratory metric, verbal answers, and task-completion time. Among the orthopedic residents, the immersive VR immersive VR group completed the learning activity and knowledge tests significantly faster for a reduction in learning time of 570%. Results among both resident and experts demonstrated the validity of immersive VR in terms of realism, the teaching content and construct applied, and skills transference.

The Value of Immersive Virtual Surgical Training in Orthopaedics

Pending Publication

Value in healthcare has traditionally been considered a relationship between the quality of the outcome for a condition balanced against the cost of care. Innovation that improves surgeon skills and reduces errors, at a reduced cost, is a direct way to improve value. Simulation technology has a positive impact on acquisition of both technical and non-technical skills, while reducing the need for costly operating room time. But the cornerstone of the value of immersive virtual reality is in translating learned skill to the real operating room. The enhanced value reaches all stakeholders. For surgeons: reduced time to learn new and variable skills versus traditional methods. For medical device manufacturers: reduced costs to bring new implants and technologies to market. For hospitals: less time in the OR, shorter surgical times and fewer errors. For patients: reduced errors and improved outcomes.