Telementoring:            Augmented Reality in Orthopaedic Education                     Ponce BA, Jennings JK, Sheppard E...
Telementoring:              Augmented Reality in Orthopaedic Education                      Ponce BA, Jennings JK, Sheppar...
Telementoring:            Augmented Reality in Orthopaedic Education                     Ponce BA, Jennings JK, Sheppard E...
Telementoring:Augmented Reality in Orthopaedic Education    Ponce BA, Jennings JK, Sheppard ED, Clay TB, May MB, Huisingh ...
Telementoring:                       Augmented Reality in Orthopaedic Education                                     Ponce ...
Telementoring:            Augmented Reality in Orthopaedic Education                     Ponce BA, Jennings JK, Sheppard E...
Telementoring:                            Augmented Reality in Orthopaedic Education                                      ...
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Telementoring: Augmented Reality in Orthopedic Education

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Telemedicine is a rapidly growing sector within medicine.  It has the ability, through audio and video technology, to connect remote healthcare providers with patients or other providers without direct contact. Telementoring, a concept within telemedicine, is when an expert physician guides another physician at a different geographic location. Access to expertise using this technology-based approach has been shown to save lives, reduce hospital stay, and reduce cost in trauma and elective surgical settings. Recently, a new interactive technology has been introduced that takes a dual reality-based approach to surgical training.

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Telementoring: Augmented Reality in Orthopedic Education

  1. 1. Telementoring: Augmented Reality in Orthopaedic Education Ponce BA, Jennings JK, Sheppard ED, Clay TB, May MB, Huisingh C, Siegel HJ. University of Alabama at Birmingham (UAB) Research or other financial support has been received from the same company as the products discussed. The Evolution of Surgical TrainingThe increase in arthroscopy, endoscopy, microscopy, and robotics in surgery has challenged the traditional side-by-sidesurgical training paradigm. Minimally invasive surgery techniques have steep learning curves which frequently placesurgeons-in-training in passive learning roles.Knowledge and skill acquisition theories emphasize the need for active participation of the student in the learning processand focus on immediate implementation of the newly acquired knowledge. Post-graduate training centers are facing theneed to evolve and utilize technical advances to educate.The benefits of surgical simulators are well documented. Virtual reality (VR) training shortens the learning curve of surgicaltrainees in addition to the benefits of not injuring patients or extending the length of operations. There are, however, anumber of challenges with VR training. Building realistic models of the human body and creating interface tools to view,hear, and manipulate these human body models remain significant hurdles to overcome.Telemedicine is a rapidly growing sector within medicine. It has the ability, through audio and video technology, to connectremote healthcare providers with patients or other providers without direct contact. Telementoring, a concept withintelemedicine, is when an expert physician guides another physician at a different geographic location. Access toexpertise using this technology-based approach has been shown to save lives, reduce hospital stay, and reduce cost intrauma and elective surgical settings. Recently, a new interactive technology has been introduced that takes a dual reality-based approach to surgical training. Augmented RealityVirtual and augmented reality technologies are well-known outside of resident education. While virtual reality can bethought as creating an entirely digital world in which a user interacts in, augmented reality can be defined as enhancingan individual’s experience in the real world through the addition of digital elements.Popular augmented reality mobile applications superimpose useful data on top of the real world, in real-time. As anexample, certain applications allow a user to view interesting or relevant historical information as he or she walks down astreet in a new city. Additionally, many augmented reality applications allow interactivity with the superimposed data.Rotating, resizing, and dynamic user input is often allowed, further enhancing the experience.Aside from popular mobile applications, field staff are using augmented reality software to view data regarding amechanical repair in real-time. A staff member, wearing a head-mounted display (HMD) can have the particular points atwhich he or she should manipulate a mechanical device be digitally highlighted for an added layer of assurance the taskis being completed correctly.While these technologies are continually increasing in pervasiveness outside of resident education, this pilot studyexamined the viability of augmented reality technology being applied in the educational arena. We utilized a VirtualInteractive Presence (VIP) (VIPAAR, Birmingham, AL) system that allows superimposition of an instructor’s hand overimaging of the surgical field in real-time. The objectives of this study were to evaluate the performance of a VIP systemimplemented in an operating room setting with respect to efficiency, safety, and teaching.
  2. 2. Telementoring: Augmented Reality in Orthopaedic Education Ponce BA, Jennings JK, Sheppard ED, Clay TB, May MB, Huisingh C, Siegel HJ. University of Alabama at Birmingham (UAB) Research or other financial support has been received from the same company as the products discussed. Examples of Augmented Reality in Current Use Google Glass: allows Word Lens: viewing weather, superimposes sending text messages, translated text on top taking pictures & video, of the real world. performing Internet searches. Google Sky Map: Wikitude: superimposes displays spatially- relevant information on registered constellation users’ surroundings. details on smartphone or tablet. Study Design• Following VA and University IRB approval, a consecutive cohort of 15 patients scheduled for arthroscopic shoulder surgery at the Birmingham Veterans Affairs (VA) Medical Center were enrolled from April -August 2012• Six orthopaedic residents, three PGY-3s and three PGY-5s, and one attending surgeon participated• For each case, the attending surgeon used the VIP system to remotely proctor one or more resident surgeons as portions of the surgical case were performed.• When the attending surgeon felt his presence was necessary in the operating room, he physically entered the case.• Following each case, the attending, resident surgeons ,anesthetist, circulator and surgical tech completed a Likert-scale questionnaire (1-5 with 1 = strongly disagree, 5 = strongly agree) that assessed their opinions on the VIP stations effect on education, safety, and efficiency. A subjective feedback section was also included on the survey.• Set up times and operative times were recorded. Operative times were historically matched to comparable prior cases by the same attending surgeon prior to the initiation of this study
  3. 3. Telementoring: Augmented Reality in Orthopaedic Education Ponce BA, Jennings JK, Sheppard ED, Clay TB, May MB, Huisingh C, Siegel HJ. University of Alabama at Birmingham (UAB) Research or other financial support has been received from the same company as the products discussed. Virtual Interactive Presence (VIP) Platform• A virtual interactive presence (VIP) platform (VIPAAR, Birmingham, AL, USA) has been developed that allows a remote surgeon to deliver real-time virtual assistance to a local surgeon over a standard Internet connection• VIP stations use software that enables the proctor to virtually “reach into” the surgical field in real-time• This creates an experience of dual reality for the local surgeon that may enhance knowledge transfer and skill acquisition• While virtual reality can be defined as immersing a user in a virtual world, dual reality merges physical realities to provide a shared first-person environment for learning• In other words, in a dual reality environment a remote surgeon can see what the operating surgeon sees and virtually identify anatomy or direct the surgical technique Virtual Interactive Presence (VIP) Setup• Two Virtual Interactive Presence (VIP) stations (VIPAAR, Birmingham, AL, USA) with an Internet Protocol (IP)-based connection • One positioned in the operating room • One positioned in surgical dictation room outside the operating room suite• Attending surgeon (proctor) was positioned at a station located in the physician’s dictation area to simulate geographic remoteness• The proctor’s hands and other surgical tools were merged directly with the arthroscopic image• The station positioned in the surgical dictation room additionally had a telestration feature that allowed the attending surgeon to draw on the image with a two-dimensional pen tool
  4. 4. Telementoring:Augmented Reality in Orthopaedic Education Ponce BA, Jennings JK, Sheppard ED, Clay TB, May MB, Huisingh C, Siegel HJ. University of Alabama at Birmingham (UAB) Research or other financial support has been received from the same company as the products discussed.Setup Schematic: Operating Room and Dictation Room Attending surgeon’s hand superimposed on arthroscopic image
  5. 5. Telementoring: Augmented Reality in Orthopaedic Education Ponce BA, Jennings JK, Sheppard ED, Clay TB, May MB, Huisingh C, Siegel HJ. University of Alabama at Birmingham (UAB) Research or other financial support has been received from the same company as the products discussed. Resident & attending survey results Attending Resident Attending Median Resident MedianCategory Statement N Mean N Mean P-value* (IQR) (IQR) (SD) (SD)Efficiency Ease of use 15 4.53 (0.52) 5 (4-5) 19 4.74 (0.45) 5 (4-5) 0.23Efficiency Reliability 15 4.60 (0.51) 5 (4-5) 20 4.60 (0.60) 5 (4-5) 0.87Efficiency Lag in motion 15 4.60 (0.51) 5 (4-5) 19 4.00 (0.82) 4 (4-5) 0.01 Safety Sufficient image 15 4.67 (0.49) 5 (4-5) 20 4.65 (0.75) 5 (4.5-5) 0.69 resolution Safety No safety concerns 15 4.60 (0.51) 5 (4-5) 20 4.75 (0.72) 5 (5-5) 0.14 Safety No interference with 15 4.60 (0.51) 5 (4-5) 20 3.85 (1.31) 4 (4-5) 0.05 surgeryTeaching Highlighting anatomy 15 4.73 (0.46) 5 (4-5) 20 4.85 (0.37) 5 (5-5) 0.41Teaching Feedback to resident 15 4.73 (0.46) 5 (4-5) 19 4.84 (0.37) 5 (5-5) 0.46Teaching Communication 15 4.67 (0.49) 5 (4-5) 20 4.75 (0.44) 5 (4.5-5) 0.61SD: standard deviation; IQR: interquartile range*p-value to compare median scores obtained via the Wilcoxon rank-sum test OR Staff survey results Staff Median Category Statement N Staff Mean (SD) (IQR) Efficiency No Increase in Workload 31 4.35 (0.91) 5 (4-5) Efficiency Unobtrusive to Workflow 35 4.17 (0.92) 4 (4-5) Efficiency Awareness of Progress of Procedure 35 4.11 (0.90) 4 (4-5) Safety Reliability 35 4.63 (0.49) 5 (4-5) Safety Sufficient Image Resolution 35 4.57 (0.50) 5 (4-5) Safety No Safety Concerns 34 4.47 (0.56) 4.5 (4-5) Safety Remote Presence Had No Adverse Effect 34 4.44 (0.70) 5 (4-5) Safety Quality of Patient Care 34 4.35 (0.73) 4 (4-5) Safety Visualization 34 4.62 (0.55) 5 (4-5) Teaching Effectiveness as Guidance Tool 35 4.23 (0.73) 4 (4-5) Teaching Feedback to Resident 35 4.43 (0.61) 4 (4-5) Teaching Communication 35 4.23 (0.73) 4 (4-5)
  6. 6. Telementoring: Augmented Reality in Orthopaedic Education Ponce BA, Jennings JK, Sheppard ED, Clay TB, May MB, Huisingh C, Siegel HJ. University of Alabama at Birmingham (UAB) Research or other financial support has been received from the same company as the products discussed. Free Form Feedback•Resident comments •Attending comments • Communication between staff and resident was • First time in my six years on staff that a resident did an precise; it allowed us to know exactly where to entire arthroscopic stabilization and the repair was debride tissue, place anchors and pass sutures excellent • Attending able to give instruction without taking over • Third year resident did entire subacromial case decompression • Improved safety – I am able to better monitor the case • I felt well supervised and yet I had an increased and give necessary instruction until my presence for the sense of autonomy being in the room by myself more complex portions is required. • Highlighted anatomy great • Improved instruction/communication – normally I say ‘go up, down, etc.’ , now can say and show what to do which • Enhanced my understanding gives resident greater involvement AND me greater supervision/control • It allowed for resident autonomy but did not sacrifice • Only time not comfortable with being remote was when staff oversight and patient safety resident did not have a good view in the subacromial space and I was unable to help as the outside camera • Better than computer or cadaveric models view was not sufficient Result Summary• No differences between attending and resident surgeons’ • VIP technology effectively allowed the attending surgeon to scores on the utility of the VIP to highlight anatomy and remotely proctor resident surgeons. provide feedback to the resident (p>.05). • Residents felt training was improved• No differences were noted between groups in the ease of • Able to do more with greater supervision use and safety during the procedure (p>.05). • Attending surgeon believed teaching effectiveness as a• Majority of resident and attending surgeons reported no proctor was improved through this technology. perceptible lag between motions (95% and 100%, • Despite being remote, attending felt had greater control respectively) (p>0.99) and no interference of the VIP with through this technology the surgical procedure (85% and 100%, respectively) (p=0.24). • No difference in surgical time and no observed complications encountered• The mean surgical times for rotator cuff and instability procedures were not significantly different with and without • Both residents and faculty believed residents were able to use of VIP (p=0.57, p=0.61, respectively). participate to a greater degree.
  7. 7. Telementoring: Augmented Reality in Orthopaedic Education Ponce BA, Jennings JK, Sheppard ED, Clay TB, May MB, Huisingh C, Siegel HJ. University of Alabama at Birmingham (UAB) Research or other financial support has been received from the same company as the products discussed. Discussion• Telemedicine is a rapidly growing field due to • Study Limitations: technological advancements, clinical need, governmental • Limited number of surgical cases • One attending surveyed incentivisation, and increased investment capital. • Small number of residents surveyed • Clinical need • No patient outcomes collected • Inclusion of only arthroscopic procedures. US experiencing a shortage of up to 200,000 physicians • Was done over a local internet network Specialized care lacking in rural areas for 80 million Americans • Government incentivization • Potential Benefits Medicare covers certain telemedicine services • Possible shortening of surgical skill learning curve VA Office of Telehealth Services in 2012 hired 1000 telehealth Potential to offset decreased resident operating exposure due to professionals work hour restrictions • Increased investment capital • Possible cost savings Telehealth sector grew from $3 to $7.7 billion in the last 5 years • With potential condensed learning curve, VIP technology may allow shorter operative times in cases involving residents without• Telementoring is a proven and validated means to compromising safety transmit skill and expertise to a site of need. • Training augmentation • VIP offers the ability to train residents with a basic orthopaedic surgical skill set, i.e. upper level residents, with in vivo training as• VIP technology provides a shared first person learning opposed to traditional cadaveric or virtual reality training environment idea for telementoring anywhere an internet connection is available • Potential applications with VIP technology • Consistent with educational theories of active • Preceptoring of practicing physicians to gain new participation and immediate implementation of newly surgical skills in real time acquired knowledge • Virtual presence of an industry rep in OR Conclusion VIP technology may effectively allow attending surgeons to remotely proctor resident surgeons. Both the attending and residents agreed that training was enhanced without sacrificing operative times. Furthermore, the attending surgeon felt this technology improved teaching effectiveness. These results are promising and support further objective quantification. References and Contact Aggarwal R, et al. Effectiveness of VR simulation for training in laparoscopic surgery. Ann Surg. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html 2007;246(5):771-779. https://www.aamc.org/download/286592/data/physicianshortage.pdf Burgess L, et al. Overview of Telemedicine Applications for Otolaryngology. The Laryngoscope. 1999; 109.9: Lange T, et al. VR in surgical training. Surg Oncol Clin N Am. 2000; 9(1): 61-79, vii. 1433-437. Larsen CR, et al. Effect of VR training on laparoscopic surgery: randomized controlled trial. Br Med J. 2009;338:b1802. Edelman DA, et al. Laparoscopic training in a 4th-year medical school surgical skills elective. J Surg Res. 2012. Latifi R, et al. Stud Health Technol Inform. 2004;104: 200-6. Web published. Mendez I, et al. Robotic Long-distance Telementoring in Neurosurgery. Neurosurgery. 2005; 56.3: 434-40. Farnworth LR, et al. Op. times in arthroscopic ACL reconst. btw. faculty and residents.Iowa Orthop J. 2001;21: Panait LA, et al. Telementoring vs On-site Mentoring in VR-Based Surgical Training. Surgical Endoscopy. 2006; 20.1: 113-18. 31–35. Schlachta C, et al. Mentoring & Telementoring Leads to Incorporation of Lap. Colon Surgery. Surg Endosc. 2010;24.4: 841-44. Grantcharov TP, et al. Performance of VR simulator to test laparoscopic skills. Am J Surg. 2003;185(2):146- Seymour NE, et al. Virtual reality training improves operating room performance. Ann Surg. 2002;236(4):458-464. 149. Shenai MB, et al. VIPAR for Remote Surgical Assistance. Neurosurgery. 2011;68(1 Suppl Operative):200-7; discussion 207. Grantcharov TP, et al. Randomized clinical trial of VR simulation for laparoscopic skills training. Br J Surg. Shortage Desig.: Health Prof. Shortage Areas & Med. Underserved Areas. Web. 31 July 2012. <http://bhpr.hrsa.gov/shortage/>. 2004;91(2):146-150. Wilson MS, et al. MIST VR: VR trainer for laparoscopic surgery assesses performance. Ann R Coll Surg Engl. 1997;79(6):404-404. Harrington D, et al. Time-Cost Analysis of Teaching Laparoscopic Entero-Enterostomy. J of Surg Edu. 2007;64.6: 342-45. Hosler MR, et al. Resident Participation in Cataract Surgery on Operative Time and Cost. Ophthalmology. 2011;119.1: 95-98. Brent A. Ponce, MD Associate Professor Stan McDuffie UAB Division of Orthopaedic Surgery Director, Clinical Services bponce@uabmc.edu stan.mcduffie@vipaar.com

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