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Volume:4 Issue:11 Number:3 ISSN#:2563-559X
OE Original

Virtual Reality Simulation for Orthopedic Surgical Training: A Review of Systematic Reviews

Authored By: OrthoEvidence

November 15, 2021

How to Cite

OrthoEvidence. Virtual Reality Simulation for Orthopedic Surgical Training: A Review of Systematic Reviews. OE Original. 2021;4(11):3. Available from: https://myorthoevidence.com/Blog/Show/157

Highlights


- In this OE Original, we systematically searched, identified, and examined evidence from systematic reviews (SRs) which were published between 2020 and 2021 with regard to the use of virtual reality (VR) simulation for orthopedic surgical training.


  • - Six SRs, in which 4 conducted narrative summary and 2 quantitative synthesis, were included.


  • - Both narrative and quantitative summaries favored the use of VR simulation for orthopedic surgical training.


  • - VR-based surgical training in orthopedics is promising but more studies, preferably randomized controlled trials (RCTs) with high methodological quality, large sample size, funded by non-industry, investigating the transferability of skills learnt via VR into actual surgical environments, are needed.





Given reasons such as patient safety and cost, surgical simulation has been increasingly demanded, explored, and adopted as an alternative for the traditional apprenticeship design of surgical residency programs which involve extensive operating room-based training for novice surgeons (Badash et al., 2016).


Synthetic models (e.g., bench top simulators and box trainers) and virtual reality (VR) simulators had been introduced over the years in order to create an inexpensive, effective, and interactive way to train novice surgeons (Mao et al., 2021).


A 2013 systematic review concluded that conventional VR-based training (i.e., computer simulation) might improve the operative performance of surgical trainees with limited prior laparoscopic experience and decrease the operating time, compared with no training or box-trainer training (Nagendran et al., 2013).


Compared to conventional non-immersive VR simulation training, the recent development of immersive VR simulation-based training, in which the individuals feel “... being physically present in a non-physical world … [surrounded] by the VR system created with images, sound, or other stimuli”, has gained extensive attention among researchers and surgeons (Radianti et al., 2020). Immersive VR training is considered to be the future of surgical and medical education for its ability to render 2-dimensional imaging into realistic 3-dimensional visualizations (Rizzetto et al., 2020).


VR-based surgical training is getting a higher demand since the COVID-19 pandemic, in which in-person activities such as surgical education are limited. In the past 2 years, several systematic reviews (SRs) have been conducted to evaluate the application of VR simulation for surgical training in orthopedics (e.g., Capitani et al., 2021; Clarke, 2021).


In this OE Original, we systematically searched, identified, and examined evidence from SRs which were published between 2020 and present with regard to the use of VR simulation for orthopedic surgical training.




Methods


Ovid MEDLINE, Ovid EMBASE, Cochrane Controlled Register of Trials (CENTRAL), and OrthoEvidence were searched from January 1, 2020 to November 2, 2021 with both indexed terms and free text terms with regard to virtual reality and surgical training.


Eligible studies should be SRs which addressed the use of VR simulation for surgical training in orthopedics, were published between January 1, 2020 to November 2, 2021 and in English. Two reviewers independently worked on the study screening and selection processes.





Results


1. Characteristics of included SRs


Among 361 retrieved records, 6 systematic reviews were eligible and included (Capitani et al., 2021; Clarke, 2021; Lakhani et al., 2021; Luzzi et al., 2021; Mao, et al., 2021; Polce et al., 2020).


The characteristics of the systematic reviews are shown in Table 1. Five out of six included systematic reviews were published in 2021 in either Europe or North America.


All 6 included SRs examined primary studies focusing on or partly involving VR simulation for orthopedic surgical training. For instance, 3 SRs focused on arthroscopic simulation (Capitani et al., 2021; Lakhani et al., 2021; Luzzi et al., 2021). The remaining 3 SRs examined evidence on VR simulation for orthopedic surgical training (Clarke, 2021), the use of immersive VR simulation for surgical training in general (Mao, et al., 2021), and different types of simulators on orthopedic surgical training (Polce et al., 2020), respectively.


The number of databases searched varied from 1 (i.e., Capitani et al., 2021) to 5 (i.e., Polce et al., 2020), with MEDLINE, EMBASE, and Cochrane databases being searched most frequently. Clarke et al. (2021) and Luzzi et al. (2021) did not report the time period for literature search, while Mao et al. (2021) searched literature published till January 2021. The rest of the SRs identified primary studies published in and before 2019.


Two SRs included only randomized controlled trials (RCTs) (Luzzi et al., 2021; Polce et al., 2020). Also, only 2 SRs conducted quantitative syntheses (Mao, et al., 2021; Polce et al., 2020).


Finally, most of the included SRs reported no funding, except Luzzi et al. (2021) and Polce et al. (2020) which did not provide relevant information. All of the SRs disclosed conflicts of interest.





Table 1. Characteristics of included systematic reviews

Study ID

Country

Objective

Databases Searched

Time Period Searched

No. of Studies Included

Including RCT* only

Quantitative Synthesis

Capitani et al. (2021)

Italy

To evaluate the current state and effectiveness of arthroscopic knee simulators

MEDLINE

2009 to September 2019

9 (5 on VR training)

No

No

Clarke (2021)

United Kingdom

To evaluate the efficacy of VR simulation in orthopedic surgical training

MEDLINE, EMBASE, Cochrane Library

Not Reported

16

No

No

Lakhani et al. (2021)

United Kingdom

To review the role of arthroscopic simulation, including VR simulation, for surgical training

MEDLINE, EMBASE, Cochrane Library

Inception to December 2019

44 (23 on VR training)

No

No

Luzzi et al. (2021)

United States

To examine the effect of arthroscopic simulator training on technical performance

MEDLINE, EMBASE, Cochrane Library

Not Reported

12 (7 on VR training)

Yes

No

Mao et al. (2021)

Canada

To evaluate the effectiveness of immersive VR for surgical skills acquisition

MEDLINE, EMBASE, CENTRAL, Web of Science, PsycInfo

January 1, 2000 to January 26, 2021

17 (12 on orthopedic training)

No

Yes

Polce et al. (2020)

United States

To examine the effects of training simulators on orthopedic surgical skill measures

MEDLINE, EMBASE, CENTRAL, Cochrane Database of Systematic Reviews

2007 to 2019

24 (15 on VR training)

Yes

Yes

RCT: Randomized Controlled Trial; VR: virtual reality.






2. Findings from the included SRs


Main findings from the included SRs are presented in Table 2. Overall, the SRs favored VR-based orthopedic surgical training. Mao et al. (2021) and Polce et al. (2021) conducted quantitative syntheses and found that VR-based surgical training was superior in terms of significantly less time-to-task completion and more improvement in objective performance scores (Table 2).


Table 2. Summary of findings of the included systematic reviews

Study ID

Main Findings

Capitani et al. (2021)

1. All 9 included studies, involving 93 residents, 3 expert surgeons, and 189 medical students, reported improved arthroscopic skills in participants after being trained with a simulator, which was either a VR simulator or a benchtop simulator.

2. Only 1 study assessed the transfer of arthroscopic skills from VR knee simulators to the operating room on a live patient.

Clarke (2021)

1. Sixteen included studies which involved 431 participants compared to VR-based orthopedic training with other types of simulators such as benchtop simulators.

2. Most included studies found that the VR-based training was superior to the controls in terms of skill and proficiency assessment.

Lakhani et al. (2021)

1. Among 44 included studies involving simulated ankle, knee, shoulder, and hip arthroscopy environments, 23 focused on VR-based training.

2. Almost all (about 95%) of included studies suggested that training with a simulator improved arthroscopic performance as well as efficiency represented by less time taken to complete tasks, fewer errors, and improved triangulation.

Luzzi et al. (2021)

1. Among 12 included studies involving 340 participants, 8 studies (in which 4 investigated VR-based training) showed improvements in performance in simulation trained groups in > 50% of the assessed outcome measures, compared to the control group.

Mao et al. (2021)

1. Among 17 included studies, 6 (5 RCTs and 1 non-RCT, 99 participants) studies were included for quantitative synthesis. The pooled SMD for post-intervention procedural time to completion from the 6 studies was -0.90 (95% CI: -1.33 to -0.47, I2: 1%, P < 0.0001, moderate certainty of evidence), favoring immersive VR-based surgical training over non-VR training in the field of orthopedics (i.e., trochanteric femoral nailing, anterior approach total hip arthroplasty, reverse shoulder arthroplasty, glenoid exposure, intramedullary nailing of tibia, pedicle screw placement).

2. Qualitative synthesis showed that participants who were trained by immersive VR demonstrated greater post-intervention scores on procedural checklists and greater implant placement accuracy, compared to non-VR training.

Polce et al. (2020)

1. Among 24 included RCTs, 7 (130 participants, 3 studies focusing on use of VR-based training for arthroscopic shoulder tasks, 1 on arthroscopic knee tasks, 1 on both, and 1 on general arthroscopic and surgical skills) and 3 (69 participants, 2 studies focusing on arthroscopic shoulder tasks, 1 on arthroscopic knee tasks) studies were included for quantitative syntheses on time-to-task completion and objective performance score, respectively.

2. In the quantitative synthesis, VR-based training was favored over the control in time-to-task completion (MD: -82.25 seconds, 95% CI: -133.64 to -30.87, I2: 39%, P = 0.002) and improvement in objective performance scores (MD: 1.24, 95% CI: 0.18 to 2.30, I2: 0%, P = 0.02).

VR: virtual reality; RCT: randomized controlled trial; SMD: standardized mean difference; 95% CI: 95% confidence interval; MD: mean difference



Discussion


In this OE Original, we systematically searched, identified, and reviewed SRs published in the past 2 years involving the application of VR simulation for surgical training in orthopedics. Our search results showed that VR-based orthopedic surgical training had become increasingly attractive recently as 6 relevant SRs were identified.


Our review found that it is challenging to quantitatively summarize evidence regarding VR-based orthopedic surgical training due to the high heterogeneity across primary studies. Most of the included SRs (4 out of 6) provided a narrative summary of evidence. These SRs all found that VR-based surgical training was favored in most of the primary studies included. However, due to the nature of narrative summary, conclusions with high certainty about VR-based orthopedic surgical training could not be drawn from these SRs.


Two of the included SRs (i.e., Mao, et al., 2021; Polce et al., 2020) conducted meta-analyses. Mao et al. (2021) quantitatively summarized the outcome post-intervention procedural time to completion from 5 RCTs and 1 non-RCT (total number of participants: 99) investigating the use of immersive VR-based training in trochanteric femoral nailing, anterior approach total hip arthroplasty, reverse shoulder arthroplasty, glenoid exposure, intramedullary nailing of tibia, and pedicle screw placement. Mao et al. (2021) found a significant difference in post-intervention procedural time to completion [standard mean difference (SMD): -0.90, 95% confidence interval (CI): -1.33 to -0.47, I2: 1%, P < 0.0001, moderate certainty of evidence] between immersive VR-based surgical training and non-VR training, favoring the former (Table 2).


Polce et al. (2020), which also conducted quantitative synthesis on the outcome time-to-task completion in 7 RCTs (total number of participants: 130) focusing on the use of VR training simulators on arthroscopic shoulder tasks, arthroscopic knee tasks, and general arthroscopic and surgical skills. Similar to results of Mao et al. (2021), Polce et al. (2020) also identified that it took trainees trained by VR simulators significantly less time to complete a task [mean difference (MD): -82.25 seconds, 95% CI: -133.64 to -30.87, I2: 39%, P = 0.002]. Additionally, VR-based training was favored over the control in the improvement in objective performance scores (3 RCTs, total number of participants: 69, MD: 1.24, 95% CI: 0.18 to 2.30, I2: 0%, P = 0.02) (Table 2).


Although the summary effect estimates from Mao et al. (2021) and Polce et al. (2020) statistically significantly favored VR-based orthopedic surgical training, the small number of participants might have limited the statistical power of the studies to reflect the true underlying effects, thus decreasing the certainty of evidence and limiting our ability to make conclusions. Moreover, as Mao et al. (2021) pointed out, the certainty of evidence might be further downgraded due to potential publication bias which arose from conflicts of interest and industry funding. More RCTs, with high methodological quality, large sample size, and funded by non-industry are warranted.


As Clarke (2021) identified, few primary studies (2 out of 16 studies) examined the trainees’ skills which were learnt from VR simulation in actual operation rooms. Middleton et al. (2017) found that there was a greater improvement in generic psychomotor skills learnt on the benchtop simulator rather than with the VR simulator, and expressed concerns that “... the VR experience may be more ‘game’ whereby subjects learn the necessary steps to pass the VR ‘test’ but fail to recognize or acquire the generic arthroscopic skills to the same degree.

In this sense, it is critical for future RCTs to examine the transferability of skills learnt via VR simulation into actual surgical environments.




Bottom Line


Although many primary studies favor VR-based orthopedic surgical training, our ability to draw conclusions is limited due to following reasons: I) most SRs we examined conducted narrative summary of evidence due to high heterogeneity across individual primary studies in aspects such as training protocols and outcome measures assessed; II) our confidence in the summary effect estimates from meta-analyses conducted by 2 SRs was limited due to small number of participants and potential publication bias as a results of industry funding. VR-based surgical training in orthopedics is promising but more studies, preferably RCTs with high methodological quality, large sample size, funded by non-industry, investigating the transferability of skills learnt via VR into actual surgical environments are needed.






References


Badash, I., et al. (2016). Innovations in surgery simulation: a review of past, current and future techniques. Annals of Translational Medicine, 4(23), 2.

Capitani, P., et al. (2021). The role of virtual reality in knee arthroscopic simulation: a systematic review. Musculoskeletal surgery. doi:https://dx.doi.org/10.1007/s12306-021-00732-9

Clarke, E. (2021). Virtual reality simulation-the future of orthopaedic training? A systematic review and narrative analysis. Advances in simulation (London, England), 6(1), 2. doi:https://dx.doi.org/10.1186/s41077-020-00153-x

Lakhani, S., et al. (2021). Arthroscopic Simulation: The Future of Surgical Training: A Systematic Review. JBJS reviews, 9(3).

Luzzi, A., et al. (2021). The Efficacy of Arthroscopic Simulation Training on Clinical Ability: A Systematic Review. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association, 37(3), 1000-1007.e1001. doi:https://dx.doi.org/10.1016/j.arthro.2020.09.018

Mao, R. Q., et al. (2021). Immersive Virtual Reality for Surgical Training: A Systematic Review. Journal of Surgical Research, 268, 40-58. doi:http://dx.doi.org/10.1016/j.jss.2021.06.045

Mao, R. Q., et al. (2021). Immersive Virtual Reality for Surgical Training: A Systematic Review. Journal of Surgical Research, 268, 40-58. doi:https://doi.org/10.1016/j.jss.2021.06.045

Middleton, R. M., et al. (2017). Simulation-Based Training Platforms for Arthroscopy: A Randomized Comparison of Virtual Reality Learning to Benchtop Learning. Arthroscopy: the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association, 33(5), 996–1003. https://doi.org/10.1016/j.arthro.2016.10.021

Nagendran, M., et al. (2013). Virtual reality training for surgical trainees in laparoscopic surgery. Cochrane Database of Systematic Reviews(8). doi:10.1002/14651858.CD006575.pub3

Polce, E. M., et al. (2020). Efficacy and Validity of Orthopaedic Simulators in Surgical Training: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. The Journal of the American Academy of Orthopaedic Surgeons, 28(24), 1027-1040. doi:https://dx.doi.org/10.5435/JAAOS-D-19-00839

Radianti, J., et al. (2020). A systematic review of immersive virtual reality applications for higher education: Design elements, lessons learned, and research agenda. Computers & Education, 147, 103778. doi:https://doi.org/10.1016/j.compedu.2019.103778

Rizzetto, F., et al. (2020). Immersive Virtual Reality in surgery and medical education: Diving into the future. The American Journal of Surgery, 220(4), 856-857. doi:10.1016/j.amjsurg.2020.04.033

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Shea, B. J., et al. (2017). AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ, 358, j4008

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