Virtual Arthroscopy Research Articles

Clinical Anatomy and Surgical Training as an Education Model for Anatomy Near‐Peer Teacher

Introduction Near-peer teacher (NPT)s have become an important element in anatomy teaching. They aid educators’ workload, facilitate information, promoting active discussion, and creating collaborative learning. The Universidad Autonoma de Nuevo Leon, has a 7-year medical school program, with Human Anatomy as a 19-week course averaging over 700 students per semester. Breaking down large anatomy groups into 5-8 student groups is possible with over 60 NPTs enrolled. The anatomy course includes interactive regional anatomy lectures, laboratory sessions (dissection, prosection, and ultrasound), and clinical and imaging case discussions. For NPTs to be effective, they are exposed to continuous education and training. NPT education teaching program The NPT training objectives are to provide knowledge and skills. Weekly 2-hour training sessions with experienced educators prepare them for the upcoming activities. NPTs are classified within the department as freshmen, sophomore, junior, or senior according to their experience (1-2, 3-4, 5-6, or ≥7 semesters as an NPT). Freshmen participate in the lectures to develop educational and teaching skills. They also increase anatomical knowledge through discussion, repetition, and teaching. They lead lectures with surveillance by educators, and are given constructive feedback. Sophomores and juniors are responsible for the clinical cases and imaging sessions. Clinical cases are reviewed with specialists (usually former NPTs) from different clinical fields, depending on the topic. Radiological studies are reviewed to compare and discuss anatomy and pathological findings. Seniors oversee the prosections and dissections with students and are responsible for teaching basic suturing skills. They are given dissection and suturing courses by specialized surgical personnel (surgeons). Clinical Anatomy and Surgical Training NPT participation is voluntary, with considerable intrinsic/extrinsic rewards. Few receive a scholarship or monetary payment for their participation. Knowledge and time are the most valuable payments provided. The following workshops are provided: Advanced Dissection Skills Advanced Suturing Skills Laparoscopic Anatomy Fundamentals of Ultrasound Ultrasound-Guided Central Venous Catheterization Fundamental Skills of Minimally Invasive Surgery Laparoscopic Dissection and Suturing Virtual Arthroscopy Diploma equivalent to 300 hours of continuous education is awarded. Sense of Belonging NPT perception surveys have reported high satisfaction and agreed the staff involved in the sessions were experts and motivated them to keep learning. NPTs have a sense of belonging in the anatomy department. When questioned if they aspired to become an anatomy professors at the UANL 76.3% agreed (67.4% as a full-time professor, 79.5% as a part-time professor, and 51.1% as a voluntarily invited professor. The percentage significantly decreased when asked regarding teaching in another course/department (56.2%) as well as teaching anatomy for another university (60.4%). Highlighting the sense of belonging.

Aktueller Stand virtueller Simulatoren für die chirurgische Ausbildung in Orthopädie und Unfallchirurgie

Die praktische chirurgische Ausbildung wird in der Orthopädie und Unfallchirurgie durch den steigenden Kostendruck in den Kliniken sowie die Verlagerung vieler Operationen in den ambulanten Bereich immer schwieriger. Das betrifft besonders die Arthroskopie, die zudem hohe Anforderungen an die Fähigkeiten des Operateurs stellt. In den letzten 20 Jahren wurden daher zahlreiche Arthroskopiesimulatoren entwickelt. Dabei handelt es sich um virtuelle Desktopsysteme, die mit einem Gelenksimulator gekoppelt sind und eine taktile Rückkopplung erlauben. Auf diese Weise können arthroskopische Basisfähigkeiten (z. B. Triangulation) oder auch arthroskopische Operationen (z. B. partielle Meniskektomie) trainiert werden. Die Systeme ermöglichen eine Erfolgskontrolle durch die Erfassung verschiedener Parameter (Operationszeit, Kamera‑/Instrumentenpfadlänge, Knorpelberührungen). Es existieren bereits Simulatoren für alle großen Gelenke. Mittlerweile liegen Daten zur Augenscheinvalidität, Inhaltsvalidität, Konstruktvalidität und zur Transfervalidität dieser Systeme vor. Die erlernten Fähigkeiten lassen sich daher auf den Erfolg im Operationssaal übertragen. Ungelöst ist bisher die Kosteneffizienz dieser Systeme. Von den Desktop-Gelenkmodell-Systemen müssen immersive Virtual-Reality(VR)-Systeme unter Verwendung von 3‑D-Brillen und taktilen Handsensoren abgegrenzt werden. Der Teilnehmende tritt der Applikation dabei meist als Avatar bei. Daher eignen sich immersive Systeme besonders zur Simulation offener Operationen (z. B. Hüftendoprothetik). Erste Studien haben auch für den Einsatz der immersiven virtuellen Realität Evidenz für Inhalts‑, Konstrukt- und Transfervalidität beim Training verschiedener offener Operationen gezeigt. Hier sind in Zukunft weitere Entwicklungen zu erwarten.

Effective Near‐peers in Anatomy

With the breaking down of 700–1,000 student semesters into discussion groups of 6–8 students, effective near‐peers are needed. Gross Anatomy is a 2nd‐semester course of a 12‐semester Medical School program. 3er‐semester students may apply as near‐peers and undergo a selection process. After this, they begin their training in accordance with seniority. Between 40 and 60 near‐peers aid professors in class and practice hours. Weekly sessions are scheduled to discuss the clinical relevance of the anatomy being taught that week. The theory is reviewed by anatomists, and clinical cases by specialists from different fields (Surgery, Gynecology, Orthopedics, Sports Medicine, Radiology, Otorhinolaryngology, Ophthalmology, Neurosurgery, Neurology, Psychiatry, ect.), according to the topic. Cadaveric dissections are guided amongst peers with the most seniority and surveillance by professors. Near‐peers, are exposed to clinical scenarios and practice, to better understand the topics, and transmit the knowledge to 2nd‐semester students during clinical sessions.With a high volume of students and a low ratio of professors, near‐peers have been an effective solution. 70.7% perceived sessions with near‐peers to have no difference from that imparted by a professor. Only 12% reported some aspects of the sessions to be confusing when given by near‐peers. Satisfaction and acceptance were high. With a high volume of near‐peers, scholarships or economic remuneration is only available to the 20 most senior and participative near‐peers. A “payment with knowledge” method and integration activities have been beneficial in keeping near‐peers satisfied and committed to the Department. Specialized courses are offered. All near‐peers from their first semester to their last may take the advanced dissection, advanced suturing, and basic fundamentals of ultrasonography courses offered by experts. Those in their 3er semester are offered laparoscopic anatomy and ultrasound‐guided vascular access courses. In their 7th semester, virtual arthroscopy, and minimally invasive surgical skill courses are added. If the near‐peers complete all 7 courses offered during their time in the Department, a Clinical Anatomy and Surgical Training Diploma are emitted.Social activities between the Department staff and near‐peers are also promoted. Social gatherings are scheduled every semester. Breakfasts are sponsored by the department after every test (3 exams and 1 final per semester). Student sports teams are encouraged, with jerseys made for all near‐peers in solidarity. Department chief and professors integrate with near‐peers. Near‐peer satisfaction and loyalty are high. Most visualize Gross Anatomy as the best depart to be a near‐peer of and are inspired to become anatomists.Support or Funding InformationNone

Virtual arthroscopy : Gaming or training concept of the future

Arthroscopy is atechnically challenging surgical procedure with arelatively shallow learning curve compared to open procedures. To become an expert special cognitive and manual abilities have to be acquired and trained. The current situation in further medical education combined with the increasing economic pressure in the medical field does not leave enough room for atime-consuming training in arthroscopic techniques. A structured simulation training could be an alternative solution to this problem. The benefits of arthroscopic simulation training are meanwhile well documented. The complex tasks that an expert carries out during arthroscopy can be fragmented into more simple and elementary exercises and can be trained in astress-free environment outside the operation room. An essential advantage of simulation training is the assessment of objective measurement parameters during the individual exercises. These parameters can be used to evaluate the learning process and performance of arthroscopic tasks. The aim of this review is to reflect the current state of simulation technology in arthroscopy and to show how simulator training can be meaningfully and effectively integrated into arthroscopic further training, exemplified by a modern medical further education concept.

Knee, Shoulder, and Fundamentals of Arthroscopic Surgery Training: Validation of a Virtual Arthroscopy Simulator

To validate the knee, shoulder, and virtual Fundamentals of Arthroscopic Training (FAST) modules on a virtual arthroscopy simulator via correlations with arthroscopy case experience and postgraduate year. Orthopaedic residents and faculty from one institution performed a standardized sequence of knee, shoulder, and FAST modules to evaluate baseline arthroscopy skills. Total operation time, camera path length, and composite total score (metric derived from multiple simulator measurements) were compared with case experience and postgraduate level. Values reported are Pearson r; alpha= 0.05. 35 orthopaedic residents (6 per postgraduate year), 2 fellows, and 3 faculty members (2 sports, 1 foot and ankle), including 30 male and 5 female residents, were voluntarily enrolled March to June 2015. Knee: training year correlated significantly with year-averaged knee composite score, r= 0.92, P= .004, 95% confidence interval (CI)= 0.84, 0.96; operation time, r=-0.92, P= .004, 95% CI=-0.96,-0.84; and camera path length, r=-0.97, P= .0004, 95% CI=-0.98,-0.93. Knee arthroscopy case experience correlated significantly with composite score, r= 0.58, P= .0008, 95% CI= 0.27, 0.77; operation time, r=-0.54, P= .002, 95% CI=-0.75,-0.22; and camera path length, r=-0.62, P= .0003, 95% CI=-0.8,-0.33. Shoulder: training year correlated strongly with average shoulder composite score, r= 0.90, P= .006, 95% CI= 0.81, 0.95; operation time, r=-0.94, P= .001, 95% CI=-0.97,-0.89; and camera path length, r=-0.89, P= .007, 95% CI=-0.95,-0.80. Shoulder arthroscopy case experience correlated significantly with average composite score, r= 0.52, P= .003, 95% CI= 0.2, 0.74; strongly with operation time, r=-0.62, P= .0002, 95% CI=-0.8,-0.33; and camera path length, r=-0.37, P= .044, 95% CI=-0.64,-0.01, by training year. FAST: training year correlated significantly with 3 combined FAST activity average composite scores, r= 0.81, P= .0279, 95% CI= 0.65, 0.90; operation times, r=-0.86, P= .012, 95% CI=-0.93,-0.74; and camera path lengths, r=-0.85, P= .015, 95% CI=-0.92,-0.72. Total arthroscopy cases performed did not correlate significantly with overall FAST performance. We found significant correlations between both training year and knee and shoulder arthroscopy experience when compared with performance as measured by composite score, camera path length, and operation time during a simulated diagnostic knee and shoulder arthroscopy, respectively. Three FAST activities demonstrated significant correlations with training year but not arthroscopy case experience as measured by composite score, camera path length, and operation time. We attempt to validate an arthroscopy simulator that could be used to supplement arthroscopy skills training for orthopaedic residents.

A Validation Study of a Novel 3-Dimensional MRI Modeling Technique to Identify the Anatomic Insertions of the Anterior Cruciate Ligament.

Background:Anatomic single bundle anterior cruciate ligament (ACL) reconstruction is the current gold standard in ACL reconstructive surgery. However, placement of femoral and tibial tunnels at the anatomic center of the ACL insertion sites can be difficult intraoperatively. We developed a “virtual arthroscopy” program that allows users to identify ACL insertions on preoperative knee magnetic resonance images (MRIs) and generates a 3-dimensional (3D) bone model that matches the arthroscopic view to help guide intraoperative tunnel placement.Purpose:To test the validity of the ACL insertion sites identified using our 3D modeling program and to determine the accuracy of arthroscopic ACL reconstruction guided by our “virtual arthroscopic” model.Study Design:Descriptive laboratory study.Methods:Sixteen cadaveric knees were prescanned using routine MRI sequences. A trained, blinded observer then identified the center of the ACL insertions using our program. Eight knees were dissected, and the centers of the ACL footprints were marked with a screw. In the remaining 8 knees, arthroscopic ACL tunnels were drilled into the center of the ACL footprints based on landmarks identified using our virtual arthroscopic model. Postprocedural MRI was performed on all 16 knees. The 3D distance between pre- and postoperative 3D centers of the ACL were calculated by 2 trained, blinded observers and a musculoskeletal radiologist.Results:With 2 outliers removed, the postoperative femoral and tibial tunnel placements in the open specimens differed by 2.5 ± 0.9 mm and 2.9 ± 0.7 mm from preoperative centers identified on MRI. Postoperative femoral and tibial tunnel centers in the arthroscopic specimens differed by 3.2 ± 0.9 mm and 2.9 ± 0.7 mm, respectively.Conclusion:Our results show that MRI-based 3D localization of the ACL and our virtual arthroscopic modeling program is feasible and does not show a statistically significant difference to an open arthrotomy approach. However, additional refinements will be required to improve the accuracy and consistency of our model to make this an effective tool for surgeons performing anatomic single-bundle ACL reconstructions.Clinical Relevance:Arthroscopic anatomic single-bundle ACL reconstruction is the current gold standard for ACL reconstruction; however, the center of the ACL footprint can be difficult to identify arthroscopically. Our novel modeling can improve the identification of this important landmark intraoperatively and decrease the risk of graft malposition and subsequent graft failure.

Performance of medical students on a virtual reality simulator for knee arthroscopy: an analysis of learning curves and predictors of performance.

BackgroundEthical concerns for surgical training on patients, limited working hours with fewer cases per trainee and the potential to better select talented persons for arthroscopic surgery raise the interest in simulator training for arthroscopic surgery. It was the purpose of this study to analyze learning curves of novices using a knee arthroscopy simulator and to correlate their performance with potentially predictive factors.MethodsTwenty medical students completed visuospatial tests and were then subjected to a simulator training program of eight 30 min sessions. Their test results were quantitatively correlated with their simulator performance at initiation, during and at the end of the program.ResultsThe mean arthroscopic performance score (z-score in points) at the eight test sessions were 1. -35 (range, -126 to -5) points, 2. -16 (range, -30 to -2), 3. -11 (range, -35 to 4), 4. -3 (range, -16 to 5), 5. -2 (range, -28 to 7), 6. 1 (range, -18 to 8), 7. 2 (range, -9 to 8), 8. 2 (range, -4 to 7). Scores improved significantly from sessions 1 to 2 (p = 0.001), 2 to 3 (p = 0.052) and 3 to 4 (p = 0.001) but not thereafter. None of the investigated parameters predicted performance or development of arthroscopic performance.ConclusionNovices improve significantly within four 30 min test virtual arthroscopy knee simulator training but not thereafter within the setting studied. No factors, predicting talent or speed and magnitude of improvement of skills could be identified.

Arthroscopic Shoulder Simulation: Can a Computer Perceive Expertise? (SS-61)

It is imperative for orthopaedic surgeons to develop and retain arthroscopic surgical skills to maintain peak performance levels. As new surgical simulators begin to become more commonplace in training there is a need to validate the model’s scoring system in perception of expertise of the user. The purpose of this study was to evaluate the biometric scoring system of a virtual reality arthroscopic simulator (ArthroVR [Simbionix USA Corporation/GMV, Cleveland, OH]) in respect to whether scores were accurate reflections of the experience of the surgeon. 41 subjects of various levels of arthroscopic shoulder experience including residents, fellows and attending surgeons were recruited to participate in this study. Each subject completed two different simulator tasks on the Arthro VR simulator. The participants were asked to do two tasks, a Bankart screw placement and a basic probe exam. All participants were asked their years of clinical practice, number of shoulder arthroscopies performed per year and their level of simulator experience. A global score was assigned for each exam based on the biometric scoring system built into the simulator. In both the probe exam and Bankart screw placement there was a 0.025 and 0.175 Pearson correlation coefficient, respectively, between the number of years in practice and the total score. There was a 0.207 and 0.323 correlation with the scoring on the probe exam and Bankart screw placement with number of scopes done in a year. This study questions the validity of the metrics used by the ArthroVR scoring system in its role in evaluation of the surgeon. In addition, this study questions its use as a measurement device in future studies. The post-test questionnaire showed that the participants felt that the simulator provided realistic haptic feedback and the instrument usage and motion were realistic. The results indicate a need for a better metrics-scoring model in the virtual arthroscopy simulator model as we increasingly use the simulators to assess residents and fellows and evaluate progress in mastering techniques in arthroscopic surgery. It is notable that the simulator is an important tool in arthroscopy training and we must continue to utilize it is as a way to prepare resident and fellows.

「画像診断の進歩」空気造影３ＤＣＴの肩関節前方不安定症に関する有用性について

The authors have demonstrated three-dimensional computed tomography imaging of soft tissues, such as the labrum and the anterior inferior glenohumeral ligament (AIGHL). We have called this imaging method 3DCT shoulder virtual arthroscopy (3DCTSVA). The aim of this study was to investigate whether 3DCTSVA can be used to visualize the internal architecture of anterior shoulder instability in comparison to surgical arthroscopy. This study involved twentytwo patients. There were 17 males and 5 females, with a mean age of 23.8 years. All patients had suspected anterior shoulder instability, as determined by patient history and physical examination, and underwent 3DCTSVA before arthroscopy. Each of the joints was injected with 20 cc air, and was then scanned immediately with a helical CT (Toshiba helical CT Aquilion slice thickness: 1 mm, slice pitch: 0.5 mm, WL: 40, WW: 250). The data obtained was entered into a workstation, and commercially available software was used to create a three-dimensional simulation of a lesion in the shoulder. Reconstruction images were then obtained. The findings of 3DCTSVA were compared with arthroscopy findings. In all 22 cases, Bankart lesion was correctly identified on 3DCTSVA. In 20 of 22 cases, AIGHL was correctly identified. In 20 of 22 cases, middle glenohumeral ligament (MGHL) was correctly identified. The sensitivity, specificity and accuracy predictive values for Bankart lesion were 100%, 100% and 100%, respectively. The sensitivity, specificity and accuracy for AIGHL were 100%, 77% and 90%. The sensitivity, specificity and accuracy for MGHL were 100%, 84% and 90%, respectively. 3DCTSVA offers fine images of the anterior labrum capsule complex of the shoulder with Bankart lesion, AIGHL and MGHL. The use of 3DCTSVA will enable us to determine the state of an anterior lesion of the shoulder before actually performing arthroscopy. 3DCTSVA is a promising method for detecting the sources of derangement of the shoulder.

Virtual MR arthroscopy of the shoulder: image gallery with arthroscopic correlation of major pathologies in shoulder instability

BackgroundThe purpose of this study was to compare virtual MR arthroscopic reconstructions with arthroscopic images in patients affected by shoulder joint instability. MR arthrography (MR-AR) of the shoulder is now a well-assessed technique, based on the injection of a contrast medium solution, which fills the articular space and finds its way between the rotator cuff (RC) and the glenohumeral ligaments. In patients with glenolabral pathology, we used an additional sequence that provided virtual arthroscopy (VA) post-processed views, which completed the MR evaluation of shoulder pathology.Materials and methodsWe enrolled 36 patients, from whom MR arthrographic sequence data (SE T1w and GRE T1 FAT SAT) were obtained using a GE 0.5 T Signa—before any surgical or arthroscopic planned treatment; the protocol included a supplemental 3D, spoiled GE T1w positioned in the coronal plane. Dedicated software loaded on a work-station was used to elaborate VAs. Two radiologists evaluated, on a semiquantitative scale, the visibility of the principal anatomic structures, and then, in consensus, the pathology emerging from the VA images.ResultsThese images were reconstructed in all patients, except one. The visualization of all anatomical structures was acceptable. VA and MR arthrographic images were fairly concordant with intraoperative findings.ConclusionsAlthough in our pilot study the VA findings did not change the surgical planning, the results showed concordance with the surgical or arthroscopic images.

CT Arthrography and Virtual Arthroscopy in the Diagnosis of the Anterior Cruciate Ligament and Meniscal Abnormalities of the Knee Joint

ObjectiveTo determine the diagnostic accuracy of CT arthrography and virtual arthroscopy in the diagnosis of anterior cruciate ligament and meniscus pathology.Materials and MethodsThirty-eight consecutive patients who underwent CT arthrography and arthroscopy of the knee were included in this study. The ages of the patients ranged from 19 to 52 years and all of the patients were male. Sagittal, coronal, transverse and oblique coronal multiplanar reconstruction images were reformatted from CT arthrography. Virtual arthroscopy was performed from 6 standard views using a volume rendering technique. Three radiologists analyzed the MPR images and two orthopedic surgeons analyzed the virtual arthroscopic images.ResultsThe sensitivity and specificity of CT arthrography for the diagnosis of anterior cruciate ligament abnormalities were 87.5%-100% and 93.3-96.7%, respectively, and those for meniscus abnormalities were 91.7%-100% and 98.1%, respectively. The sensitivity and specificity of virtual arthroscopy for the diagnosis of anterior cruciate ligament abnormalities were 87.5% and 83.3-90%, respectively, and those for meniscus abnormalities were 83.3%-87.5% and 96.1-98.1%, respectively.ConclusionCT arthrography and virtual arthroscopy showed good diagnostic accuracy for anterior cruciate ligament and meniscal abnormalities.

Virtual arthroscopy of the visible human female temporomandibular joint

Purpose: This study was designed to obtain views of the temporomandibular joint (TMJ) by means of computed arthroscopic simulation (virtual arthroscopy) using three-dimensional (3D) processing. Material and Methods: Volume renderings of the TMJ from very thin cryosection slices of the Visible Human Female were taken off the Internet. Analyze AVW software (Biomedical Imaging Resource, Mayo Foundation, Rochester, MN) on a Silicon Graphics 02 workstation (Mountain View, CA) was then used to obtain 3D images and allow the navigation “fly-through” of the simulated joint. Results: Good virtual arthroscopic views of the upper and lower joint spaces of both TMJs were obtained by fly-through simulation from the lateral and endaural sides. It was possible to observe the presence of a partial defect in the articular disc and an osteophyte on the condyle. Virtual arthroscopy provided visualization of regions not accessible to real arthroscopy. Conclusion: These results indicate that virtual arthroscopy will be a new technique to investigate the TMJ of the patient with TMJ disorders in the near future.

Virtual arthroscopy of the visible human female temporomandibular joint

Virtual arthroscopy of the visible human female temporomandibular joint