CORR Insights®: Is the Virtual Reality Fundamentals of Arthroscopic Surgery Training Program a Valid Platform for Resident Arthroscopy Training?

Where Are We Now?

Growing up, I thoroughly enjoyed video games, much to my parents’ chagrin. But as a young attending in 2005, I always felt that there was a correlation between arthroscopic skills and exposure to video games—this was both for myself and my trainees. Do video games develop some portion of a person’s brain and/or help us do work in a four-dimensional world (length, width, height, and time/motion) using a two-dimensional instrument? I am not sure. But fast forward 16 years, and virtual reality (VR) is part of all aspects of our daily life. It is therefore natural that surgical training is working feverishly to adopt this technology as a platform for education and surgical simulation [3-5].

Although there are several different platforms one can use, their effectiveness is difficult to verify [5], and like any other technology or product, there will be various platforms or vendors that will require validation prior to adoption. In this study, Vaghela and colleagues [6] prospectively recruited orthopaedic interns (novices), residents (intermediates), and fellows and attendings (experts) to complete the VR Fundamentals of Arthroscopic Surgery Training (FAST) program over a 1-year period from four major orthopaedic training programs on a voluntary basis. Surgeons of any arthroscopic experience were included, and only those with prior experience on the VR FAST program were excluded. The program consisted of eight modules: three basic camera modules (Image Centering, Horizon Control, and Telescoping), three advanced camera modules (Periscoping, Trace-the-Line, and Trace-the-Curve), and two instrumented bimanual-dexterity modules (Probe Triangulation and Gather-the-Stars). Using these methods, the authors found that six of eight VR FAST modules lacked construct validity, and they found no correlation between arthroscopic experience and ambidextrous performance. Two modules demonstrated construct validity; however, refinement and expansion of the modules was deemed necessary with further validation in large prospective trials so that pass-fail thresholds can be set for use in high-stakes examinations [6]. In my opinion, the true value of this technology in the future is to have it complement in vivo training that residents/fellows receive. This technology can be used to allow trainees to learn to master certain technical feats such as proficient knot tying or using different perspectives to perform tasks around a joint.

Where Do We Need To Go?

After reading the current study, I am excited about the future. However, this paper has caused me to contemplate several unanswered questions. For example, if these training modules have a gap in the ability to demonstrate efficacy and differentiation between skill levels, then what technological advancements will we need to close that gap? With the pandemic and disruption of resident education and case volume, is this technology ready to fill a gap in our educational training? The findings in this study make me think that the answer is “not yet.” The VirtaMed platform cannot effectively differentiate different skill levels reliably. Perhaps the question is not how different groups of surgeons (novice, intermediates, and experts) compare on one platform when executing the same tasks. In reality, how often do we as educators make different surgeons compete head on in when performing a procedure? Almost never. In a future study, researchers should ask: How does this educational platform compare to currently available platforms [1]? Indeed, a recent study using the VirtaMed platform did find that when comparing the VirtaMed simulator to cadavers for surgical education in an objective manner, that VR simulators were just as effective as cadavers in means of training subjects [2]. To be cost efficient, these platforms need to be more effective than current readily available platforms such as cadaveric specimens.

How Do We Get There?

A VR experience should seamlessly simulate a real surgical environment, but this requires a real investment from potential stakeholders in healthcare and medical education. While many VR investors in the recreational and gaming world have seen a sizeable ROI, the investment of resources to develop VR specifically for application in surgical training has not been met with the same enthusiasm as other industries

Not only are we in need of Level I studies, it is likely that expert validators or users are needed to help design modules and test them to ensure replication of the most realistic in vivo environments. We likely need to consider the development of VR applications like the way we approach product development such as new shoulder replacements. This will need a long-term iterative collaborative approach between content experts (surgeons), software engineers, and industry-specific experts.

While traditional methods of training such as lecture, cadaveric training, and surgical apprenticeship have been the mainstay of education for decades, the ability for medical education to continue to evolve will need these VR platforms to become more integrative and validated via Level 1 studies. The types of procedures that lend themselves to a VR platform with assessment using objective measures includes arthroscopic procedures as well as diagnostic arthroscopy, tissue preparation, portal placement, and knot tying.