Advancements in surgical simulation training in orthopaedics

By Usman Ahmed
Consultant Orthopaedic Surgeon at Worcestershire Acute Hospitals NHS Trust and BOA Education and Careers Committee Member


Orthopaedic surgery demands precision, skill, and expertise. Surgeons in have to navigate complex musculoskeletal structures, making the need for rigorous training paramount. Clinical simulation is the use of tools/devices/environments to mimic a particular aspect of clinical care in a safe way.

It has been a hot topic for many decades now and for the most part the emergence of simulation tools in a transformative way has not really happened in a manner that makes it superior to real hands on experience. In an ideal world, surgical simulation would provide a controlled environment for surgeons to practice and refine their skills. With COVID-19 forcing the issue there has been greater investment nationally to really develop these opportunities however, longer term, sustainability and integration is the key.

In this article, we will explore the current landscape of surgical simulation training in orthopaedics, examining the available technologies, their expenses, the quality of simulations, and the success rates observed. Furthermore, we will delve into future technologies that hold promise for enhancing orthopaedic surgical training.

Current simulation

Simulation can be divided into a few broad areas, but Cardoso et al.1, broke down the physical simulation into:

  • Organic – animal or cadaveric
  • Inorganic – synthetic or electronic

There are also non-physical simulation. If we adhere to the above definition, even a simple case-based discussion can be considered a form of simulation. Discussing a case becomes a bit like a 'choose your own adventure', with the assessor dynamically responding to your answers with a variety of outcomes guided by their experience. This often drifts into real world practice when performing surgery and the consultant looks at you and says, "what are you going to do now?".

The value in work-based assessments is often lost as they are more increasingly seen as a box ticking exercise for the portfolio. Not considering that an opportunity to have the discussion could enhance the thought process, understanding and knowledge could be rued later. I certainly do remember a few opportunities where we all could have done better.

Every surgeon, when doing their pre-operative preparation will run a case through their mind, we didn't really define what we were doing but now we do have terminology for this. Mental preparation (running through the steps of case) all the way through to Cognitive Simulation which puts (rightfully!) the surgeon in the same league as elite athletes with the application of psychological techniques to enhance the mental preparation further.

Prior to COVID-19, physical simulation in orthopaedics consisted of:

  • Organic – Animal: At the most junior levels such as seen in the Basic Surgical Skills course or ATLS, though the use of animal is not seen as frequently in the UK.
  • Inorganic – Synthetic: The magical dusty time spent with saw-bones and handling all the different pieces of kit on the multitude of trays that we use.
  • Organic – Cadaveric: At junior levels utilised observationally for anatomy training, but more advanced industry sponsored cadaveric workshops are available for technique specific practice.

But what about Inorganic – Electronic? COVID-19 has really accelerated the amount of investment being made into this sector and we have seen some amazing potential.

  1. Virtual Reality (VR) /Augmented Reality (AR) simulations: One of the most prominent advancements in surgical simulation training is the integration of VR. VR simulations offer an immersive experience, allowing surgeons to practice procedures in a realistic 3D environment. Companies like Touch Surgery and Osso VR provide platforms that cover a range of orthopaedic procedures, from joint replacements to fracture fixations. But having visited BOA congresses, it is apparent industry has taken this up educationally (and for marketing!) to demonstrate how their kit is used.
  2. Haptic feedback systems: Haptic feedback adds a tactile dimension to virtual simulations, providing the sensation of touch during surgical manoeuvres. This is particularly crucial in orthopaedics where the tactile sense is integral. Touch-sensitive devices like the HapticMaster offer realistic force feedback, enabling surgeons to feel the resistance encountered during bone drilling or implant placement.
  3. 3D Printing and cadaveric simulations: Physical models created through 3D printing offer a tangible alternative to virtual simulations. These models replicate patient-specific anatomies, allowing surgeons to practice on realistic structures. Additionally, cadaveric simulations provide hands-on experience with human tissues. While these methods offer a realistic feel, they often come with logistical challenges and may not be widely accessible. 3D printing has been widely taken up particularly in complex reconstructive surgeries where pathological models are printed to aid surgical planning.

There are associated concerns though with the Inorganic - Electronic simulation. Firstly the expense. The cost of implementing surgical simulation training programs varies depending on the technology used. VR simulations generally require an initial investment in hardware and software, including VR headsets and haptic devices. Companies like Precision OS have developed orthopaedic-specific VR modules that can be integrated into training programs. The cost of these systems can be huge and as we have seen, there are plenty of additional expenses that can be incurred. The equipment is pricey, needs to be maintained and also kept clean. The added costs of estates, staff and infection prevention, not to mention the insurance and servicing costs can made some of these products unobtainable. If we couple this with the fact that the users will need expert supervision (both with respect to technology and education) the amount of time needed starts climbing. We know that the key to becoming competent is repeated exposure to a certain task/skill. The logistics of delivering this on a frequent basis across large geographic areas provides many challenges.

3D printing and cadaveric simulations, on the other hand, can incur significant expenses for materials, equipment, and storage. However, the advantage lies in their ability to closely mimic real surgical scenarios, providing a unique learning experience.

The expense of implementing surgical simulation training is often a barrier for widespread adoption. While larger institutions and teaching hospitals may have the financial resources to invest in state-of-the-art simulation labs, smaller clinics and training programs may find it challenging to allocate funds for such technologies. This also may lead to challenges in attainment with those rotating to dedicated simulation centres gaining a potentially unfair advantage.

The second big issue is the quality of simulations.

  1. Realism and immersion

VR simulations have the potential to excel in providing a high level of realism and immersion. Surgeons can interact with a lifelike environment, enhancing their spatial awareness and decision-making skills. However, the quality of simulations can vary, and not all virtual platforms offer the same level of fidelity. A viability study in the Midlands looking at a desktop simulation programme noted that even though the simulations were well aligned to key curriculum points, the uptake amongst the demographic group was very poor. The feedback suggested that this group had 'played' with the simulation a couple of times but found it to be insufficient for their needs, though the value for more junior groups has been a bit clearer.

  1. Accuracy of anatomical representation

The accuracy of anatomical representation is crucial for effective surgical training. 3D printing and cadaveric simulations are particularly strong in this aspect, as they replicate the intricacies of human anatomy with high precision. VR simulations strive for accuracy, but limitations in current technology may result in some simplifications.

  1. Feedback mechanisms

Haptic feedback systems play a vital role in enhancing the quality of simulations by providing realistic touch sensations. The effectiveness of haptic feedback varies across different devices, and continuous improvements in this technology are expected to further enhance the overall quality of surgical simulations.

Success rates and learning outcomes

Numerous studies have explored the impact of surgical simulation training on the performance and confidence of orthopaedic surgeons. Results generally indicate positive outcomes, with participants showing improved technical skills and a decreased likelihood of errors during actual surgeries.

  1. Skill transfer to the operating room: The effectiveness of simulation training in transferring skills to real-world surgical scenarios is a key metric. Studies have shown that surgeons who undergo simulation training often exhibit enhanced performance in the operating room, with improved efficiency and reduced procedural errors.
  2. Confidence and competence: Surgical simulation has been associated with increased confidence and competence among trainees. The ability to practice repeatedly in a risk-free environment contributes to a surgeon's self-assurance, which is crucial for successful outcomes in clinical practice.
Future technologies in orthopaedic surgical simulation
  • Artificial intelligence (AI) integration: The integration of AI into surgical simulations holds great potential. AI algorithms could provide personalised feedback, identify areas for improvement, and adapt simulations based on individual learning curves. This technology could revolutionise the efficiency and effectiveness of orthopaedic surgical training provided that the underlying software and hardware is up to speed.
  • Augmented Reality (AR): A technology that overlays digital information onto the real-world environment as mentioned earlier, offering a unique perspective for surgical training. AR applications could provide real-time guidance during procedures, enhancing the surgeon's ability to navigate complex anatomies and ensuring precision.
  • Sensor Technology for Performance Metrics: Advanced sensor technologies can capture and analyse a surgeon's movements during simulations. This data can be used to assess proficiency, identify areas for improvement, and tailor training programs to address specific weaknesses.

The field of surgical simulation training in orthopaedics has witnessed significant advancements, offering a range of technologies to enhance the skills of aspiring and practicing surgeons. VR, haptic feedback systems, 3D printing, and cadaveric simulations provide diverse options, each with its own set of advantages and limitations. However, the journey toward optimal cost-effective surgical simulation in orthopaedics is still in progress.

While current technologies have shown promise in improving skill acquisition, confidence, and competence, challenges such as cost and accessibility persist. The expense associated with implementing high-quality simulation programs remains a barrier for many institutions and programmes. As technology continues to evolve, addressing these challenges will be crucial to making surgical simulation training more widely accessible.

Future technologies, including AI integration, AR, and advanced sensor technologies, hold promise for further enhancing the effectiveness of orthopaedic surgical simulations. These innovations have the potential to provide more personalised and adaptive training experiences, ultimately leading to better-prepared surgeons.

In conclusion, the trajectory of surgical simulation training in orthopaedics is undoubtedly positive, with advancements paving the way for more effective and immersive learning experiences. However, the field is not yet fully mature, and overcoming current challenges is necessary to make these technologies universally accessible and ensure their seamless integration into orthopaedic training programs. The ongoing commitment to research, development, and collaboration will play a crucial role in steering the future of orthopaedic surgical simulation towards a more refined and universally applicable standard.

But a cautionary word – technology still needs a human master, so before jumping in and spending your budgets on some fancy kit, be aware that you will need just as much money, if not more, to be able to train the teachers to use the technology to its maximum potential.

  1. Cardoso SA, Suyambu J, Iqbal J, Cortes Jaimes DC, Amin A, Sikto JT, et al. Exploring the Role of Simulation Training in Improving Surgical Skills Among Residents: A Narrative Review. Cureus. 2023 Sep 4;15(9):e44654.