Blow Out Your Knee? Hope Your Surgeon’s Got a VR Headset

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With all due respect to games, porn, and lion kings, virtual reality’s killer app might just be saving lives. At a Stanford-affiliated children’s hospital, pediatric cardiologists use an interactive virtual heart to help young patients and their families better understand congenital defects. Researchers in Maryland put on headsets to study viruses in the pursuit of a universal flu vaccine. In Minnesota, surgeons stood inside a VR model of the circulatory systems of conjoined twins—which proved integral to the ensuing separation surgery.

Great uses, certainly, but all variations on The Fantastic Voyage (or Innerspace, if you prefer). Now, building on a pile of evidence stretching back more than a decade, VR is finally getting clinical validation for actual surgical training. In a pilot study conducted at UCLA and presented recently at a meeting of orthopedic surgeons, medical students who practiced a common procedure in VR significantly outperformed those who used conventional preparation methods.

All the experience, none of the marrow: A (real) surgical trainee puts the (virtual) finishing touches on a (virtual) tibia.

Osso VR

This wasn’t a highly specialized procedure, but the bread and butter of orthopedic surgeons everywhere: fixing a bone fracture. Specifically, a break in the tibia, the larger of the two bones in your lower leg. The tibia isn’t the most commonly broken bone, but it certainly figures prominently in Most Gruesome Sports Injuries lists. Joe Theisman? Tibia. Gordon Hayward? Tibia. Paul George? Sweet lord, tibia. (If you didn’t see them when they happened, there’s video, but you probably don’t want to watch.) As with most long bones, the preferred method to fix a fractured tibia is by inserting a nail into the cavity—an intramedullary nail (IMN), as it’s known clinically.

It’s not exactly easy. You’ve got to make the incision, insert a guidewire at the correct angle, ream out the incision with a drill, build the nail assembly, insert the nail, then place a proximal interlocking screw to help keep the nail static. That’s a lot of steps and a lot of tools—and not a lot of opportunity to practice. “It’s complicated if you don’t know the anatomy that well,” says Kevin Varner, chair of orthopedics and sports medicine at Houston Methodist.

You could use bone models or cadavers, but with the power tools involved, those are expensive, single-use propositions. The best training typically comes during a medical residency: You watch senior residents, then you assist in a procedure, then maybe you perform some—but always under the direct supervision of your attending physician. As a result, says Michael P. Ast, an assistant professor of orthopedic surgery at the Hospital for Special Surgery in New York City, flying truly solo might not happen until you’re out of school entirely: “When you went into practice, your first intramedullary nail was probably the first one where you had your own hands doing every step of the procedure, with no one else watching.”

In the UCLA study, 20 first- and second-year med students got a five-minute hands-on tutorial with the drill used in the IMN procedure, then got split into two groups of 10—one that received a printed technique guide with photographs and step-by-step instructions, the other that received similar instructions by way of a virtual-reality training module from Osso VR, a Palo Alto-based surgical-training company. All students could take as much time as they wanted with their training materials, then each was taken to a room to perform a simulated IMN procedure on a commonly used bone model system. Two weeks later, they all came back and repeated the procedure.

Each time, the students’ test procedures were evaluated on two different scales—one noting whether they had completed each step of the surgery correctly, the other grading them on their instrument handling, the time and elegance with which they performed the procedure, and other subjective measures. On nearly every measure, the VR-trained group outperformed the standard-training group, with significant improvement in inserting the nail and the most complex steps. (In fact, only VR-trained students successfully put together the nail assembly.) There was even more difference in the subjective proficiency grading: VR-trained students outperformed the others significantly in all five areas. And when they came back two weeks later, the VR-trained students improved over their previous performance on every single count—while the standard-trained students declined in two areas.

A couple of caveats should probably enter the discussion at this point. For one, Osso VR’s CEO did his medical residency at UCLA, and one of the company’s advisers works there currently. For another, this was a presentation rather than a publication, meaning the study hasn’t been peer-reviewed to fully vet its methodology. Still, there’s a lot of promise here—something that doesn’t surprise Ast, whose hospital has offered Osso’s training platforms to its 50 residents over the last year. “The beauty of the people we’ve seen train in VR is that they’re way more prepared when they actually get in the operating room,” he says. “As opposed to spending all their time thinking what’s the next step, they’re able to talk and listen and observe the unique surgical considerations of that patient, because they’re already completely comfortable with the procedure.”

Even surgeons who haven’t used VR see its promise as a training tool. “There’s a lot of benefit in trying to do things in a VR environment,” Varner says, “whether it’s improving hand-eye coordination or just understanding the steps of the procedure. I learned by doing more than 100 tibial nails when I was in my residency, but I think there’s a lot to learn from these kinds of things.” A lot, of course, doesn’t mean everything. “I’ve known people that play a lot of racing computer games,” Varner adds. “That doesn’t make them a better race car driver.”


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