Immersive virtual reality in orthopedic surgery as elective subject for medical students

Surgical simulations are used for training skills in various disciplines to create an approximately realistic learning environment without the risk of patient harm [19]. The use of cadavers was a long-established gold standard training modality but there are limitations, such as high costs, limited accessibility, non-pathologic states, and ethical considerations. Therefore, new options for surgical training have been explored [14].

Virtual reality (VR) technologies are currently being used in orthopedic training simulators to increase surgical accuracy to improve outcomes and reduce complications [27‐30]. Multiple studies have suggested that the use of VR during orthopedic residency programs improves surgical performance [9, 15, 22, 25] and VR simulators have been shown to be more effective in supporting the learning of residents than benchtop trainers or synthetic models [8, 15, 20]. Furthermore, the use of VR has been positively received by residents and associated with increased comfort in perceived surgical skills [1, 13].

Improvements in technology allowed the development of immersive virtual reality (iVR), which provides the advantages of conventional VR, whilst operating on low-cost, mobile, commercially available hardware [19, 24]. Mao et al. defined iVR as a fully virtual interactive simulation with a 3-dimensional (3D) environment projected onto a head-mounted display (HMD), allowing for a 360° visual immersion and real-time manipulation of virtual items. Other sensory modalities (e.g., haptic, auditory) were not required to meet this criterion [19]. Although there is extensive evidence that training on VR simulators improves technical skills, the use in orthopedic training programs lags behind other surgical specialties [1]. Training simulators are only available in a few residency programs [29] and only one study showed usage of VR in curricular education in orthopedic and trauma surgery for medical students [10].

Data are lacking on the experience of iVR use in the curricular training of medical students. The aim of this study was to describe the framework conditions and implementation for the use of VR techniques in the teaching of medical students in orthopedic surgery and to obtain user feedback of medical students on this educational method. In addition, the effects of iVR on students’ theoretical and procedural learning were evaluated.

The aim of this study was to describe the implementation of an iVR operating theater as an elective course for medical students and to evaluate its effect on the students’ theoretical and practical learning. The use of VR stimulation in orthopedic training programs is less common than in other surgical specialties [1] and training simulators are rarely available for orthopedic residents [29]. Regarding medical students or surgical interns, other disciplines show a plethora of VR tools in medical education for non-residents [5]. In orthopedic surgery, only one study reported the usage of VR training for medical students, introducing students to an intensive care unit and prehospital care [10]. Atli et al. described an iVR application for neurosurgical education for medical students with almost the same setup as the presented study: 12 students were included in an elective course in neurosurgery for 1 year, including an iVR-based learning platform [3]. As shown in both studies, the implementation of VR training for medical students is feasible for a low number of students as an elective course; however, the technical infrastructure and access to hardware and software may be a bottleneck when more students are involved. The approximate cost of iVR platforms varies between US$ 1500 and US$ 8000, depending on the institutional licensing agreements [6, 11, 16], which is estimated to be up to 34.1 times more cost-effective than traditional training methods [18]. Nevertheless, factors such as device maintenance and output, management of software problems and updates as well as device instructions must be considered and were only manageable in the setup described with the support of the faculty’s Skills and Simulation Center.

In the evaluation of Atli et al. all students agreed that utilizing iVR helped them gain a deeper understanding of neuroanatomy and neurosurgery and 69% claimed to have a better understanding of neurosurgical skills. All of the students evaluated the course to be a valuable learning experience and iVR a useful learning tool [3]. These findings are in line with the results of the present study and indicate favorable results and high acceptance of iVR in medical education especially in surgical disciplines. The authors concluded that iVR training may improve confidence and therefore could contribute to improved participation during surgical rotations and better understanding for operative procedures [3, 19], which is also confirmed by the results of the present study. The students’ evaluations in both studies are in good agreement with the largely positive user feedback of surgical residents evaluating the usability of different iVR simulators [4, 11, 18]. In a systematic review, Mao et al. stated that residents enjoyed iVR training significantly more than theoretical training and tended to perceive iVR training to be more useful than theoretical training in general. This was especially the case for novice surgeons [19], which are probably closer to students in terms of their level of training than specialized surgeons.

In the present study, students stated to be very satisfied with the iVR training and that they would recommend the tool to a fellow student. This confirms findings from other studies that reported iVR training to be realistic, usable and useful in surgical training [4]. The main point of criticism was the frequently insufficient tactile feedback in the applications. This flaw was widely reported in other investigations [2, 3, 11, 16, 21]. In 2008 Praamsma et al. showed that an auditory stimulus using bone drilling sounds may act in a same way as haptics for expert surgeons [23]; however, the iVR tool used in the present study emitted a realistic auditory stimulus (e.g., bone drilling) to supplement tactile feedback and despite this was criticized by the users to be insufficient. While this may be explained by the lack of experience in medical students, the main point of criticism confirms that improving haptic and auditory feedback may further improve the efficacy of iVR training [19]. A second consideration of using iVR training is the occurrence of motion sickness, caused by a mismatch between the sensory systems by using HMDs and resulting in nausea and ultimately vomiting [10]. Motion sickness was reported by 23% of the participants by Holla et al. [10], whereas Barré et al. reported slight to moderate symptoms of motion sickness in 30% of their participants [4]. In the present investigation, one of the participants reported severe symptoms of motion sickness, while 55% reported weaker symptoms. This wide variety may be explained by differences in the HMD used and different levels of practice with iVR training by the participants, as postural discomfort has shown to decrease with increased practice [4]. As a solution for participants showing symptoms, chewing gum during VR training is known to reduce symptoms of motion sickness [12] and a study showed that less nausea is reported when the HMD can be adjusted to properly fit the interpupillary distance [10, 26].

The positive effects of VR training in surgery were summarized in a recent systematic review by Mao et al. who found 11 controlled trials comparing iVR training with non-VR training and in 2 of these trials the control group was taught with written material plus video explanations or video material only, which is comparable to our test setup [16, 17, 19]. Mao et al. found that groups that were trained with iVR performed 18–43% faster in surgical procedures as compared to control groups without iVR training, demonstrated greater postintervention scores on procedural checklists and greater implant placement accuracy [19]. Lohre et al. evaluated whether iVR improved learning effectiveness in 18 senior orthopedic surgery residents with comparable surgical experience during a single training course. The residents were randomized into two groups: one group received training on the PrecisionOS platform version 3.0 (PrecisionOS Technology) and the control group received training using a surgical video of a reverse shoulder arthroplasty (RSA) with augmented baseplate. Following the intervention, each participant was tested on theoretical knowledge about the procedure and had to perform RSA in a cadaveric model. The iVR-trained group significantly outperformed the non-VR group in the objective structured assessment of technical skills (OSATS) and the verbal questioning scores [17]. This is comparable to the results of the presented study to some degree as the students in the VR group also showed statistically significant higher procedural knowledge compared to the non-VR group and statistically improved in their final score after 5 weeks of training. Logishetty et al. compared a total of 24 surgical trainees: 12 completed a 6-week VR training program, while the non-VR group received only conventional preparatory materials. Afterwards all 24 trainees had to perform a cadaveric total hip arthroplasty (THA) and their technical and non-technical surgical performance was measured by a THA-specific procedure-based assessment. The VR-trained surgeons completed 33% more key steps than controls, were 12% more accurate in component orientation and were 18% faster than the non-VR group, showing higher procedural knowledge and psychomotor skills [16]. Furthermore, Blumstein et al. compared 20 students with and without VR training in intramedullary nail fixation of tibial shaft fractures. The VR-trained students significantly outperformed the other conventionally trained group on the procedure-specific checklist and showed significantly higher knowledge of the surgical instruments [7]. Again, all these findings are supported by the presented data, showing significantly higher procedural knowledge after iVR training.

Immersive virtual reality can be easily implemented into the curriculum of medical students and is highly appreciated by the participants. Students prefer more iVR in surgical training in their medical education and state that it improves their understanding of surgical skills. iVR statistically improves the procedural knowledge of surgical steps compared to instructional videos.