Augmented Reality to Teach Arthroscopic Shoulder Surgery in Developing Countries

Abstract

Arthroscopy has traditionally been taught to residents or other surgeons through one-on-one in person guided training in the operating room. Simulators have also been used to increase the availability of exposure to arthroscopy training. However, these simulators have significant limitations and cannot be definitively correlated to improvement in arthroscopy skills in the operating room. In developing countries, arthroscopic surgical skills are not often emphasized in training programs and in particular, shoulder arthroscopic skills may or may not be taught. The use of telementoring through augmented reality (AR) has been demonstrated in Orthopaedic education. In the context of arthroscopy, AR can facilitate the collaborative efforts of improving surgical teaching methods through visual and audio interactions in the operating room, regardless of geographic boundaries. AR is both an economical and easily-reproducible teaching tool, making it readily accessible to developing nations across the globe. We have developed a private platform (SurgTime) using augmented reality in the operating room from a remote location. The purpose of our study is to determine whether the platform is reliable and if it may have usefulness in teaching arthroscopic shoulder surgical skills in developing countries. Ten Orthopaedic surgeons with an interest in shoulder surgery were recruited for the project. They were all part of a collaborative effort initially sponsored by the American Academy of Orthopaedic Surgeons (AAOS) and the Romanian Orthopaedic and Traumatologic Society (SROT) to bring modern shoulder surgical techniques to Romania. Over a 5 year period, 8 Romanian surgeons, one Serbian surgeon and one Bosnian surgeon were enlisted in the program. On a bimonthly basis over a period of 3 months, the European surgeons were invited to connect via a simple internet connection to the telementoring surgeon in the United States and with real time interactive presence, were able to interact with the telementoring surgeon. Via the private platform (SurgTime), the observing surgeons were able to visualize the same arthroscopic picture that the operating surgeon was seeing, ask real time questions during the surgery and also use augmented reality (AR) graphics to point out structures or clarify surgical techniques. The observing surgeons along with the telementoring surgeon filled out a Likert-scale questionnaire regarding the educational utility, efficiency of use and safety of the system. There were 10 successful connections out of 12 attempts from the telementoring surgeon to the mentee surgeons over a 3 month period. The first two attempts were unsuccessful because of the poor connectivity of the internet via a wireless connection from the telementoring surgeon’s operating room. The next 10 straight attempts were successful once a hard wired connection was established in the operating room. Ten arthroscopic shoulder surgeries were performed and observed via the private platform on the observers’ home or office computer, cell phone, tablet or any other device that received an internet connection. There was no loss of connectivity via the telementoring surgeon and the observing surgeons for all 10 cases. There was an average of 3 surgeons viewing each surgical procedure (range 2-5). All of the observing surgeons agreed that the system was easy to use, reliable, easy to connect to, and had sufficient image resolution with no significant lag in motion or audio transmission. They also felt it was useful to highlight shoulder anatomy and pathology and to observe the telementoring surgeon’s surgical technique. The observing surgeons did not feel there were any safety concerns with the procedure nor did it interfere with the surgical procedure. The single telementoring surgeon (senior author) also agreed that the system was easy to use, reliable, easy to connect to, and had sufficient image resolution with no significant lag time in motion or audio transmission. He felt it was useful to not only highlight shoulder anatomy and pathology but also to demonstrate surgical techniques. The telementoring surgeon also did not feel there were any safety concerns with the procedure nor did it interfere with the surgical procedure. Both the observing surgeons and the telementoring surgeon felt it was an effective teaching tool. The real time interactive presence (RTIP) technology using augmented reality was efficient, safe and effective as a teaching tool in teaching shoulder arthroscopy. This first trial with our platform found it to be reliable in connecting the experienced surgeon here in the United States telementoring a group of Orthopaedic surgeons learning shoulder arthroscopy in Romania, Serbia and Bosnia. Its successful application in this context has the potential to shape the future of global Orthopaedic training and in developing countries. By providing real time instruction of surgical instruction from a remote location, this technology can accelerate the learning curve of doctors in developing countries, enhance knowledge transfer and skill acquisition, and improve arthroscopic surgical technique, patient safety, and operative outcomes.