Virtual Reality and Augmented Reality Are Uniquely Suited to Hip Arthroscopy Education and Reveal Adequate Face, Content, and Construct Validity: A Systematic Review With Expert Commentary.

PurposeTo summarize literature outlining the efficacy and validity of virtual reality (VR) and augmented reality (AR) simulation in hip arthroscopy training.MethodsThree databases were searched on February 9th, 2025 for studies investigating the validity of VR/AR simulation for hip arthroscopy training. Data on participant details, simulation specifics, and validity (e.g. face, construct, and content) were included. Descriptive statistics were used to report results.ResultsNine studies (one level I, one level II, seven level IV) comprising 218 participants were included, 37 (16.9%) being considered as “experts”. The majority of studies (7/9; 77.8%) were analyses of one session, with two studies comparing progress during sessions over time. Five studies investigated face validity, where the majority of participants (>70%) in each study found that the simulators were realistic (>7/10 or >6/7 via Likert scale) in all elements apart from tactile feedback. Eight studies evaluated construct validity. Four studies compared the safety performance of experts and non-experts, three (75%) finding statistically lower amounts of iatrogenic tissue damage in the expert group (p<=0.002). Three of four (75%) studies found that experts had lower completion times in either a diagnostic or surgical module (p<=0.03) than non-experts. One study reported lower iatrogenic damage via soft-tissue or bone collisions (p<0.0001) and completion times (p<0.001) in the seventh session of VR simulation, relative to the initial first three sessions in junior learners.ConclusionVR/AR simulation training for hip arthroscopy demonstrates adequate face, content, and construct validity. Generally, VR/AR simulations were rated realistic by users apart from tactile feel. Participants, particularly junior learners improved in minimizing iatrogenic tissue damage and decreasing completion times over multiple sessions. Experts generally outperformed non-experts in the majority of performance metrics, suggesting high construct validity.

Extended-Reality Technologies: An Overview of Emerging Applications in Medical Education and Clinical Care.

Surgical trainees are finding it increasingly more challenging to meet operative requirements and coupled with the effects of COVID-19, we face a future of insufficiently trained surgeons. As a result, virtual reality (VR) simulator training has become more prevalent and whilst more readily accepted in certain arthroscopic fields, its use in hip arthroscopy (HA) remains novel. This project aimed to validate VR high-fidelity HA simulation and assess its functional use in arthroscopic training.Seventy-two participants were recruited to perform two basic arthroscopic tasks on a VR HA simulator, testing hip anatomy, scope manipulation and triangulation skills. They were stratified into novice (39) and experienced (33) groups based on previous arthroscopy experience. Metric parameters recorded from the simulator were used to assess construct validity. Face validity was evaluated using a Likert-style questionnaire. All recordings were reviewed by 2 HA experts for blinded ASSET score assessment.Experienced participants were significantly faster in completing both tasks compared with novice participants (p&lt;0.001). Experienced participants damaged the acetabular and femoral cartilage significantly less than novice participants (p=0.011) and were found to have significantly reduced path length of both camera and instrument across both tasks (p=0.001, p=0.007), demonstrating significantly greater movement economy. Total ASSET scores were significantly greater in experienced participants compared to novice participants (p=0.041) with excellent correlation between task time, cartilage damage, camera and instrument path length and corresponding ASSET score constituents. 62.5% of experienced participants reported a high degree of realism in all facets of external, technical and haptic experience with 94.4% advising further practice would improve their arthroscopic skills. There was a relative improvement of 43% in skill amongst all participants between task 1 and 2 (p&lt;0.001).This is the largest study to date validating the use of simulation in HA training. These results confirm significant construct and face validity, excellent agreement between objective measures and ASSET scores, significant improvement in skill with continued use and recommend VR simulation to be a valuable asset in HA training for all grades.

Development and Validation of a Novel Robotic Procedure Specific Simulation Platform: Partial Nephrectomy

MP23-09 A NOVEL TECHNIQUE FOR SIMULATED SURGICAL PROCEDURES USING 3D PRINTING TECHNOLOGY

The study examines the problem of using augmented and virtual reality in the process of blended learning in general secondary education. Analysis of recent research and publications has shown that the use of augmented and virtual reality in the educational process has been considered by scientists. However, the target group in these studies is students of higher education institutions. Most of the works of scientists are devoted to the problem of introducing augmented reality into the traditional educational process. At the same time, the use of augmented and virtual reality technologies in the process of blended learning remains virtually unexplored. The study analyzes the meaning of the concept of "blended learning". The conceptual principles of blended learning are considered. It has been found that scholars differ in their understanding of the concept of "blended learning". Sometimes researchers distinguish between the components of blended learning: full-time and online learning. The study presents the special advantages of blended learning and the taxonomy of blended learning. It was found that there are some difficulties in implementing blended learning. The article outlines the practical use of virtual and augmented reality. The definition of augmented and virtual reality is given. The mixed reality is considered as a separate kind of notion. Separate applications of virtual and augmented reality that can be used in the process of blended learning are considered (MEL Chemistry VR; Anatomyou VR; Google Expeditions; EON-XR). As a result of the study, the authors propose possible ways to use augmented reality in the educational process. The model of using augmented and virtual reality in blended learning in general secondary education institutions was designed. It consists of the following blocks: goal; teacher’s activity; forms of education; teaching methods; teaching aids; organizational forms of education; pupil activity and results. Based on the model, the methodology of using augmented and virtual reality in blended learning in general secondary education was developed. The methodology contains the following components: target component, content component, technological component and resultant component. The methodology is quite universal and can be used for any subject in general secondary education. The types of lessons in which it is expedient to use augmented (AR) and virtual reality(VR) are determined. Recommendations are given at which stage of the lesson it is better to use AR and VR tools (depending on the type of lesson).

User Experience and Engagement in the Reality–Virtuality Continuum: A Special Issue Guest Editorial

PurposeWe evaluate the face, content, and construct validity of a portable hip arthroscopy module in a regional orthopaedic unit.MethodsParticipants were recruited from a regional orthopaedic centre, and categorized into novice (0 arthroscopies), intermediate (1-29 arthroscopies), and expert (>50 arthroscopies) groups based on reported experience in arthroscopy. Face and content validity was evaluated by feedback from users immediately following completion of modules. Objective measurements, including time taken and subjective measurements consisting of simulation software metrics including, cam lesion locations attempts, scope strikes on bone, healthy bone burred, and cam lesion burred. Scores achieved by experts were recorded, and the median score was set at the level at which proficiency was demonstrated. Participant feedback on perceived educational use was collected following completion.ResultsIn total, 20 participant results were included for analysis. Good face and content validity was expressed by participants with previous arthroscopic experience. Number of scope strikes within the simulator-derived metrics accurately discerned between levels of experience. Novices had a mean of 5 strikes per attempt (SD a mean of 5.8 strikes (SD 4.1). There was a significant difference between expert and novice groups (P = .01), and expert and intermediate groups (P = .002). No significant difference between overall performance scores achieved by participants in expert, intermediate, and novice groups (62% vs 55% vs 50% P = .15). This demonstrates incomplete construct validity of the simulator software-derived metrics.ConclusionsThis hip arthroscopy simulator demonstrated acceptable face and content validity, with incomplete construct validity of simulator software metrics. Participants reported high levels of satisfaction with the module, highlighting that the addition of haptic feedback would be beneficial to improve procedural steps. Incorporation of tactile feedback to the modulator components would likely enable the software to accurately delineate between levels of experience.Clinical RelevanceThis study demonstrates good face and content validity. The addition of haptic feedback in a hip arthroscopy simulator may improve learning.

Validation of a Virtual Reality–Based Hip Arthroscopy Simulator

Primary school students often find it difficult to differentiate two dimensional and three-dimensional geometric shapes. Taking advantage of the ability of Virtual Reality (VR) and Augmented Reality (AR) to visualize 3D objects, we evaluate the potential of VR and AR technologies for teaching the lesson of geometric solids to primary school children. To the best of our knowledge there are no previous cases in the literature describing a comparative evaluation of VR and AR technologies in education, and more specifically in the field of mathematics for primary school children. An experimental evaluation was staged to test the following hypothesis: Hypothesis 1: VR and AR applications make the teaching of mathematics more interactive and interesting and they also contribute to a more efficient learning and understanding of mathematical concepts. Hypothesis 2: The use of VR applications is more effective when compared to AR applications for mathematics teaching activities. For the needs of the experimental evaluation, we designed a lesson plan comprised of three activities: Classification of shapes into solid or plane shapes, identification of solid shapes appearing in a typical city environment, and classification of solid shapes. The lesson plan was implemented based on the traditional method that utilizes printed material, three related VR and three AR applications. The developed VR and AR applications for the current research do not require specialized equipment. For the AR applications, the users only need to use their mobile device or tablet and for VR applications they only need to use a mobile phone and low-cost virtual reality glasses. As part of the study 30 fourth, fifth and sixth class primary school students were divided equally into the control group who used the traditional teaching method, and the AR and VR groups who used AR and VR applications respectively. Participants were provided with questionnaires before (pre-test) and after the test (post-test) to measure factors such as user attention, presence, enjoyment, science knowledge, auditory knowledge, and visual knowledge. According to the results, new technologies in education in the form of virtual and augmented reality improve interactivity and student interest in mathematics education, contributing to more efficient learning and understanding of mathematical concepts when compared to traditional teaching methods. No significant difference was observed between virtual and augmented reality technologies with regards to the efficiency of the methods that contribute to the learning of mathematics, suggesting that both virtual and augmented reality display similar potential for educational activities in Mathematics. Based on statistical evidence Hypothesis 1 was accepted and Hypothesis 2 was rejected. The current research is one of the first attempts ever to compare VR and AR technologies for Mathematics teaching activities in primary school. The findings of our research can provide valuable feedback to educators and developers who plan to use or develop VR or AR technologies for educational activities. Given that these days VR and AR applications, like the ones used in the experimental evaluation, do not require highly specialized equipment, the introduction of AR and VR based activities both for in-class and extra curriculum activities provide a promising way for more efficient Mathematics training activities.

MP23-08 INITIAL VALIDATION DURING DEVELOPMENT OF LOW COST ALTERNATIVE TO THE DV-TRAINER USING THE HYDRA SYSTEM

The goal of this study was to establish face, content, and construct validity of NOViSE—the first force-feedback enabled virtual reality (VR) simulator for natural orifice transluminal endoscopic surgery (NOTES). Fourteen surgeons and surgical trainees performed 3 simulated hybrid transgastric cholecystectomies using a flexible endoscope on NOViSE. Four of them were classified as “NOTES experts” who had independently performed 10 or more simulated or human NOTES procedures. Seven participants were classified as “Novices” and 3 as “Gastroenterologists” with no or minimal NOTES experience. A standardized 5-point Likert-type scale questionnaire was administered to assess the face and content validity. NOViSE showed good overall face and content validity. In 14 out of 15 statements pertaining to face validity (graphical appearance, endoscope and tissue behavior, overall realism), ≥50% of responses were “agree” or “strongly agree.” In terms of content validity, 85.7% of participants agreed or strongly agreed that NOViSE is a useful training tool for NOTES and 71.4% that they would recommend it to others. Construct validity was established by comparing a number of performance metrics such as task completion times, path lengths, applied forces, and so on. NOViSE demonstrated early signs of construct validity. Experts were faster and used a shorter endoscopic path length than novices in all but one task. The results indicate that NOViSE authentically recreates a transgastric hybrid cholecystectomy and sets promising foundations for the further development of a VR training curriculum for NOTES without compromising patient safety or requiring expensive animal facilities.

Learning anatomy traditionally has depended on traditional techniques like human cadaveric dissection and the use of textbooks. As technology advances at an ever-rapid speed, there are revolutionary ways to learn anatomy. A number of technologies, techniques and methodologies are utilised in anatomical education, but ones specifically receiving a lot of interest and traction is that of augmented reality and virtual reality. Although there has been a surge in interest in the use of these technologies, the literature is sparse in terms of its evaluation as to the effectiveness of such tools. Therefore, the purpose of this study is to examine in greater detail the literature specifically to see what the best practice in this field could be. By undertaking a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched for articles in both Web of Science and PubMed. Using the terms "augmented reality and teaching anatomy" yielded 88 articles. We then used "virtual reality and teaching anatomy" which resulted in 200 articles. We examined these articles, including that on augmented reality and virtual reality used to teach anatomy to undergraduate and postgraduate students, residents, dentistry, nursing and veterinary students. Articles were excluded if they were systematic reviews, literature reviews, review articles, news articles, articles not written in English and any literature that presented how a virtual model was created without the evidence of students testing it. The inclusion and exclusion criteria for virtual reality were the same as augmented reality. In addition, we examined the articles to identify if they contained data which was quantitative, qualitative or both. The articles were further separated into those which were pro, neutral or against for the use of these digital technologies. Of the 288 articles, duplicate articles totalling 67 were removed and 134 articles were excluded according to our exclusion criteria. Of the 31 articles related to augmented reality, 30 were pro, one neutral and no articles against the use of this technology. Fifty-six articles related to virtual reality were categorised resulted in 45 pro, eight neutral and three against the use of this technology. Overall, the results indicate most articles identified related to both virtual and augmented reality were for the use of those technologies, than neutral or against. This systemic review highlights the recent advances of both augmented reality and virtual reality to implementing the technology into the anatomy course.

In the field of surgery, major changes that have occurred include the advent of minimally invasive surgery and the realization of the importance of the ‘systems’ in the surgical care of the patient (Pierorazio &amp; Allaf, 2009). Challenges in surgical training are two-fold: (i) to train the surgical residents to manage a patient clinically (ii) to train them in operative skills (Singh &amp; Darzi,2013). In Pakistan, another issue with surgical training is&#x0D; that we have the shortest duration of surgical training in general surgery of four years only, compared to six to eight years in Europe and America (Zafar &amp; Rana, 2013). Along with it, the smaller number of patients to surgical residents’ ratio is also an issue in surgical training. This warrants formal training outside the operation room. It has been reported by many authors that changes are required in the current surgical training system due to the significant deficiencies in the graduating surgeon (Carlsen et al., 2014; Jarman et al., 2009; Parsons, Blencowe, Hollowood, &amp; Grant, 2011). Considering surgical training, it is imperative that a surgeon is competent in clinical management and operative skills at the end of the surgical training. To achieve this outcome in this challenging scenario, a resident surgeon should be provided with the opportunities of training outside the operation theatre, before s/he can perform procedures on a real patient. The need for this training was felt more when the Institute of Medicine in the USA published a report, ‘To Err is Human’ (Stelfox, Palmisani, Scurlock, Orav, &amp; Bates, 2006), with an aim to reduce medical errors. This is required for better training and objective assessment of the surgical residents. The options for this training include but are not limited to the use of mannequins, virtual patients, virtual simulators, virtual reality, augmented reality, and mixed reality. Simulation is a technique to substitute or add to real experiences with guided ones, often immersive in nature, that reproduce substantial aspects of the real world in a fully interactive way. Mannequins, virtual simulators are in use for a long time now. They are available in low fidelity to high fidelity mannequins and virtual simulators and help residents understand the surgical anatomy, operative site and practice their skills. Virtual patients can be discussed with students in a simple format of the text, pictures, and videos as case files available online, or in the form of customized software applications based on algorithms. In a study done by Courtielle et al, they reported that knowledge retention is increased in residents when it is delivered through virtual patients as compared to lecturing (Courteille et al., 2018).But learning the skills component requires hands-on practice. This gap can be bridged with virtual, augmented, or mixed reality. There are three types of virtual reality (VR) technologies: (i) non-immersive, (ii) semi-immersive, and (iii) fully immersive. Non-immersive (VR) involves the use of software and computers. In semi-immersive and immersive VR, the virtual image is presented through the head-mounted display(HMD), the difference being that in the fully immersive type, the virtual image is completely obscured from the actual world. Using handheld devices with haptic feedback the trainee can perform a procedure in the virtual environment (Douglas, Wilke, Gibson, Petricoin, &amp; Liotta, 2017). Augmented reality (AR) can be divided into complete AR or mixed reality (MR). Through AR and MR, a trainee can see a&#x0D; virtual and a real-world image at the same time, making it easy for the supervisor to explain the steps of the surgery. Similar to VR, in AR and MR the user wears an HMD that shows both images. In AR, the virtual image is transparent whereas, in MR, it appears solid (Douglas et al., 2017). Virtual augmented and mixed reality has more potential to train surgeons as they provide fidelity very close to the real situation and require fewer physical resources and space compared to the simulators. But they are costlier, and affordability is an issue. To overcome this, low-cost solutions to virtual reality have been developed. It is high time that we also start thinking on the same lines and develop this means of training our surgeons at an affordable cost.

Virtual reality (VR) and augmented reality (AR) have been combined with physical rehabilitation and psychological treatments to improve patients' emotional reactions, body image, and physical function. Nonetheless, no detailed investigation assessed the relationship between VR or AR manual therapies (MTs), which are touch-based approaches that involve the manipulation of tissues for relieving pain and improving balance, postural stability and well-being in several pathological conditions. The present review attempts to explore whether and how VR and AR might be integrated with MTs to improve patient care, with particular attention to balance and to fields like chronic pain that need an approach that engages both mind and body. MTs rely essentially on touch to induce tactile, proprioceptive, and interoceptive stimulations, whereas VR and AR rely mainly on visual, auditory, and proprioceptive stimulations. MTs might increase patients' overall immersion in the virtual experience by inducing parasympathetic tone and relaxing the mind, thus enhancing VR and AR effects. VR and AR could help manual therapists overcome patients' negative beliefs about pain, address pain-related emotional issues, and educate them about functional posture and movements. VR and AR could also engage and change the sensorimotor neural maps that the brain uses to cope with environmental stressors. Hence, combining MTs with VR and AR could define a whole mind-body intervention that uses psychological, interoceptive, and exteroceptive stimulations for rebalancing sensorimotor integration, distorted perceptions, including visual, and body images. Regarding the technology needed to integrate VR and AR with MTs, head-mounted displays could be the most suitable devices due to being low-cost, also allowing patients to follow VR therapy at home. There is enough evidence to argue that integrating MTs with VR and AR could help manual therapists offer patients better and comprehensive treatments. However, therapists need valid tools to identify which patients would benefit from VR and AR to avoid potential adverse effects, and both therapists and patients have to be involved in the development of VR and AR applications to define truly patient-centered therapies. Furthermore, future studies should assess whether the integration between MTs and VR or AR is practically feasible, safe, and clinically useful.