Development and Validation of a Virtual Reality Haptic Femoral Nailing Simulator.

OBJECTIVE:To create a virtual reality (VR) femoral nailing simulator combining haptics and image intensifier functionality and then carry out validation studies to assess its educational value. DESIGN:The simulator consisted of a 3D virtual environment, a haptic device and 3D printed drill handle and a VR headset. The environment was created using a video game development engine, interfaced with plugins to allow haptic feedback and image intensifier functionality. Two tasks were created within the simulator as part of an antegrade femoral intramedullary (IM) nail procedure: proximal guidewire entry and distal locking.For the validation study, participants performed the above tasks on the simulator. Metrics were collected including time taken, number of X-rays and tool distance travelled and used to assess construct validity. A questionnaire was then completed to assess authenticity and content validity. SETTING:Simulator development in centre for simulation and engagement science laboratory. Validation study in a teaching hospital environment. PARTICIPANTS:Orthopedic specialist trainees and consultants. RESULTS:Surgeon experience (number of IM nails performed/postgraduate year) correlated with significantly improved task performance. More experienced surgeons took less time, used fewer X-rays and had greater economy of movement than less experienced surgeons. Authenticity and content validity were well rated, with criticisms primarily due to hardware limitations. CONCLUSIONS:To our knowledge this is the first orthopedic simulator to combine immersive VR with haptics and full image intensifier functionality. By combining multiple aspects of surgical practice within a single device, we aimed to improve participant immersion and educational value. Our work so far has focused on technical skills, demonstrating good authenticity, content and construct validity, however our findings show promise in other applications such as nontechnical skill development and assessment.