Experience using immersive virtual reality simulation during an AO trauma regional course in Latin America

INTRODUCTION

Virtual reality is defined as “the use of computer modeling and simulation to enable a person to interact with an artificial three-dimensional visual or other sensory environment through devices such as goggles, headsets, gloves, or body suits.”^[1] Virtual reality has been used in orthopedics for several years now, both as a training and assessment tool.^[2,3]

In recent years, immersive virtual reality (IVR) simulators using commercially available devices have emerged due to the creation of two startups led by orthopedic surgeons. Using headsets, the virtual reality simulation takes up all the users’ field of vision as they become completely immersed in the virtual experience. The users interact with the environment using handheld controllers. This new form of simulation allowed virtual reality to become more portable and accessible.^[4]

The use of extended reality technologies in surgical training and simulation is the most developed and validated of all the current applications today.^[5-7] Despite this, IVR has not been formally included in orthopedic continuous surgical training, and skill transferability that impacts patient outcomes has yet to be proved.^[8,9]

This report aimed to present our experience during the first AO trauma regional courses in Latin America that incorporated the use of IVR simulation as a hands-on activity as part of the program.

MATERIALS AND METHODS

The advanced principles of fracture treatment regional courses in Rio de Janeiro, Brazil, consisted of three courses with 40 participants each with a total of 120 participants and 52 faculties. Twelve faculties were assigned to the IVR activity, with 20 participants each time.

All the course activities were performed 3 times to accommodate all participants. The trochanteric femoral fracture osteosynthesis with a trochanteric femoral nail practical exercise took place on the 2^nd day and was set up for 1 h. In the first half an hour of the activity, 20 participants used the IVR simulation for the trochanteric femoral nail, while the other 20 did the traditional hands-on exercise. After 30 min, both groups switched places. This rotation was repeated 6 times.

Room and headset setup

Twenty squares measuring two-by-two meters were marked with tape on the floor. These were then used to set up the virtual boundaries for the headset. All headsets were set up so that they would launch directly to the trochanteric femoral nail module [Figure 1].

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Figure 1:

Meta Quest 2 headset and controllers.

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Activity execution

The activity was designed like any hands-on educational activity during AO courses. Objectives were established at the beginning and a brief tutorial on how to use the headset, controllers, and software was shown to the participants by the practical director. This lasted <5 min. After the introduction and tutorial, each participant had the opportunity to start the module and do it at their own pace. Assistance from faculties and staff was available. Five minutes before the practical ended, take-home messages were delivered, and participants were asked to answer a survey about the perceived usefulness of IVR. Each participant had a personal face covering. After each group used the headsets, the silicon covers and the controls were cleaned [Figure 2].

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Figure 2:

Room setup and participants using individual headsets for the practical exercise.

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RESULTS

There were 120 participants in the three courses. Eighty-four participants were from Brazil, 20 were from Colombia, three were from Peru, two were from Argentina, two were from Ecuador, and one was from each of the following countries: Chile, Panama, Paraguay, and Mexico. One hundred and three participants were males and 12 were females. The median age for participants was 33.86 years of age, ranging from 27 to 64 years of age. Twelve faculty members were assigned to the IVR activity.

Seventy-four persons answered the survey. Forty-six participants (62%) considered that the IVR simulation was like reality. Fifty-five (76.38%) thought that IVR was helpful in the learning process. Sixty-six people (91.6%) referred they would like to use IVR for training and 67 (93%) would be willing to use IVR again.

Although we did not specifically measure this, we did notice that most participants only needed help in the first 5–6 min of hands-on use of the IVR. After this time, almost all of them were able to follow the in-simulation instructions. In addition, several participants completed the whole procedure, including augmentation – even though it was not part of the program. Some even did the trochanteric femoral nail module twice. Faculty members subjectively perceived that participants who did the IVR practice first referred that they found it easier to perform the hands-on activity. Some participants also mentioned that they felt that they knew the steps better after using IVR simulation.

DISCUSSION

To the best of our knowledge, this is the first time a massive and structured educational activity involving the use of IVR took part during a fractures management course. It was also the first time, TFN-ADVANCED™ Proximal Femoral Nailing System (TFNA) module was used in Latin America.

With the appearance of the Meta Quest 2 by Meta Platforms Inc, IVR has become much more portable than the previous version available in Latin America. Today, only the headset and controllers are needed, and the new software has been developed by Osso VR (San Francisco, California) in partnership with the Johnson and Johnson Institute for ©DePuy Synthes (Johnson and Johnson) implants. This technology has just been introduced in Latin America in 2022.

Several randomized trials have shown that IVR can improve translational technical and nontechnical skills acquisition over traditional learning both in students and senior-level orthopedic residents.^[10-13]

So far, it has been demonstrated that simulation, and simulation with IVR can improve surgical skill acquisition, with trainees showing improvement in time to complete a procedure, procedural checklist scores, and implant placement accuracy.^[8,12-14] It can also help trainees be more confident with their skills.^[8]

Despite these results, formal introduction to residency and training programs has been slow, even with arthroscopic simulators.^[9] Some of the main difficulties for formal training program implementation with VR are that there is no consensus on establishing training sessions or measuring outcomes. There are also few instructors or faculty prepared to work with IVR simulation. Hence, IVR utilization is usually unsupervised and the students are frequently left to learn alone.^[9,15] This has been especially true during medical device companies’ activities with IVR.

A seven-item task list for educators using VR simulation was proposed by Camp for the continuous educational use of VR simulators. Defining the primary goals for the educational activity is the first one.^[9] For our training session, the main objective was that participants became familiar with the new technology. We consider that going forward, establishing educational goals when using IVR simulation is paramount for the success of educational activities. Otherwise, the activity becomes an entertainment session with novel technology. This opens the possibility for detractors to call IVR simulation a “realistic videogame” but not an educational tool.

Other barriers that have been identified up until now for the integration of simulation-based training into surgical education are a lack of methods for the evaluation of surgical skills in the operating room, lack of consensus for proficiency-based progression, limitations for training in problem-solving and surgical adversity, and lack of consensus for the remediation of poor performance.^[16]

CONCLUSION

This was the first time, IVR simulation was implemented as a massive and structured educational activity during the principles of fracture treatment course. A systematic way of implementing IVR simulation sessions with educational goals needs to be developed for these activities. Faculties and support personnel need to be prepared to assist in these activities.