Virtual Reality Simulation Facilitates Resident Training in Total Hip Arthroplasty: A Randomized Controlled Trial

Published:April 08, 2019DOI:



      No study has yet assessed the efficacy of virtual reality (VR) simulation for teaching orthopedic surgery residents. In this blinded, randomized, and controlled trial, we asked if the use of VR simulation improved postgraduate year (PGY)-1 orthopedic residents’ performance in cadaver total hip arthroplasty and if the use of VR simulation had a preferentially beneficial effect on specific aspects of surgical skills or knowledge.


      Fourteen PGY-1 orthopedic residents completed a written pretest and a single cadaver total hip arthroplasty (THA) to establish baseline levels of knowledge and surgical ability before 7 were randomized to VR-THA simulation. All participants then completed a second cadaver THA and retook the test to assess for score improvements. The primary outcomes were improvement in test and cadaver THA scores.


      There was no significant difference in the improvement in test scores between the VR and control groups (P = .078). In multivariate regression analysis, the VR cohort demonstrated a significant improvement in overall cadaver THA scores (P = .048). The VR cohort demonstrated greater improvement in each specific score category compared with the control group, but this trend was only statistically significant for technical performance (P = .009).


      VR-simulation improves PGY-1 resident surgical skills but has no significant effect on medical knowledge. The most significant improvement was seen in technical skills. We anticipate that VR simulation will become an indispensable part of orthopedic surgical education, but further study is needed to determine how best to use VR simulation within a comprehensive curriculum.

      Level of Evidence

      Level 1.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Arthroplasty
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Bell R.H.
        • Biester T.W.
        • Tabuenca A.
        • Rhodes R.S.
        • Cofer J.B.
        • Britt L.D.
        • et al.
        Operative experience of residents in US general surgery programs: a gap between expectation and experience.
        Ann Surg. 2009; 249: 719-724
        • Kalun P.
        • Wagner N.
        • Yan J.
        • Nousiainen M.T.
        • Sonnadara R.R.
        Surgical simulation training in orthopedics: current insights.
        Adv Med Educ Pract. 2018; 9: 125-131
        • Aggarwal R.
        • Moorthy K.
        • Darzi A.
        Laparoscopic skills training and assessment.
        Br J Surg. 2004; 91: 1549-1558
        • Rosenthal R.
        • Gantert W.A.
        • Scheidegger D.
        • Oertli D.
        Can skills assessment on a virtual reality trainer predict a surgical trainee’s talent in laparoscopic surgery?.
        Surg Endosc. 2006; 20: 1286-1290
        • Carpenter J.E.
        • Hurwitz S.R.
        • James M.A.
        • Jeffries J.T.
        • Marsh J.L.
        • Martin D.F.
        • et al.
        ABOS surgical skills modules for PGY-1 residents. Am Board Orthop Surg.
        • Seeley M.A.
        • Kazarian E.
        • King B.
        • Biermann J.S.
        • Carpenter J.E.
        • Caird M.S.
        • et al.
        Core concepts: orthopedic intern curriculum boot camp.
        Orthopedics. 2016; 39: e62-e67
        • Seymour N.E.
        • Gallagher A.G.
        • Roman S.A.
        • O'Brien M.K.
        • Bansal V.K.
        • Andersen D.K.
        • et al.
        Virtual reality training improves operating room performance. Results of a randomized, double-blinded study.
        Ann Surg. 2002; 236: 458-463
        • Dwyer T.
        • Wadey V.
        • Archibald D.
        • Kraemer W.
        • Shantz J.S.
        • Townley J.
        • et al.
        Cognitive and psychomotor entrustable professional activities: can simulators help assess competency in trainees?.
        Clin Orthop Relat Res. 1999; 474: 926-934
        • Alaker M.
        • Wynn G.R.
        • Arulampalam T.
        Virtual reality training in laparoscopic surgery: a systematic review & meta-analysis.
        Int J Surg. 2016; 29: 85-94
        • Guerriero L.
        • Quero G.
        • Diana M.
        • Soler L.
        • Agnus V.
        • Marescaux J.
        • et al.
        Virtual reality exploration and planning for precision colorectal surgery.
        Dis Colon Rectum. 2018; 61: 719-723
        • Kin T.
        • Nakatomi H.
        • Shono N.
        • Nomura S.
        • Saito T.
        • Oyama H.
        • et al.
        Neurosurgical virtual reality simulation for brain tumor using high-definition computer graphics: a review of the literature.
        Neurol Med Chir (Tokyo). 2017; 57: 513-520
        • Piromchai P.
        • Avery A.
        • Laopaiboon M.
        • Kennedy G.
        • O’Leary S.
        Virtual reality training for improving the skills needed for performing surgery of the ear, nose or throat.
        Cochrane Database Syst Rev. 2015; 9: CD010198
        • Aïm F.
        • Lonjon G.
        • Hannouche D.
        • Nizard R.
        Effectiveness of virtual reality training in orthopaedic surgery.
        Arthroscopy. 2016; 32: 224-232
        • Bartlett J.D.
        • Lawrence J.E.
        • Stewart M.E.
        • Nakano N.
        • Khanduja V.
        Does virtual reality simulation have a role in training trauma and orthopaedic surgeons?.
        Bone Joint J. 2018; 100-B: 559-565
        • Jacobs C.A.
        • Christensen C.P.
        Factors influencing patient satisfaction two to five years after primary total knee arthroplasty.
        J Arthroplasty. 2014; 29: 1189-1191
        • Vaughan N.
        • Dubey V.N.
        • Wainwright T.W.
        • Middleton R.G.
        A review of virtual reality based training simulators for orthopaedic surgery.
        Med Eng Phys. 2016; 38: 59-71
        • Stern P.J.
        • Albanese S.
        • Bostrom M.
        • Day C.S.
        • Frick S.L.H.W.
        • et al.
        The orthopaedic surgery milestone project the accreditation council for graduate medical education and The American Board of Orthopaedic Surgery 2015.
        • Ferguson P.C.
        • Kraemer W.
        • Nousiainen M.
        • Safir O.
        • Sonnadara R.
        • Alman B.
        • et al.
        Three-year experience with an innovative, modular competency-based curriculum for orthopaedic training.
        J Bone Joint Surg Am. 2013; 95 (1-6): e166
        • Alman B.A.
        • Ferguson P.
        • Kraemer W.
        • Nousiainen M.T.
        • Reznick R.K.
        Competency-based education: a new model for teaching orthopaedics.
        Instr Course Lect. 2013; 62: 565-569
        • Gofton W.T.
        • Dudek N.L.
        • Wood T.J.
        • Balaa F.
        • Hamstra S.J.
        The Ottawa surgical competency operating room evaluation (O-score).
        Acad Med. 2012; 87: 1401-1407
        • Kusuma S.K.
        • Garino J.P.
        Total hip arthroplasty.
        in: Garino J.P. Beredjiklian P.K. Adult reconstruction & arthroplasty: core knowledge in orthopaedics. Mosby Elsevier, Philadelphia, PA2007: 108-146
        • Gonzalez Della Valle A.
        • Padgett D.E.
        • Salvati E.A.
        Preoperative planning for primary total hip arthroplasty.
        J Am Acad Orthop Surg. 2005; 13: 455-462
        • Charles M.N.
        • Bourne R.B.
        • Davey J.R.
        • Greenwald A.S.
        • Morrey B.F.
        • Rorabeck C.H.
        • et al.
        Soft-tissue balancing of the hip: the role of femoral offset restoration.
        J Bone Joint Surg. 2004; 86: 1078-1088
        • Schulz K.F.
        • Altman D.G.
        • Moher D.
        • CONSORT Group
        CONSORT 2010 Statement: updated guidelines for reporting parallel group randomized trials.
        Obstet Gynecol. 2010; 115: 1063-1070
        • Kolozsvari N.O.
        • Feldman L.S.
        • Vassiliou M.C.
        • Demyttenaere S.
        • Hoover M.L.
        Sim one, do one, teach one: considerations in designing training curricula for surgical simulation.
        J Surg Educ. 2011; 68: 421-427
        • Spencer F.C.
        Observations on the teaching of operative techniques.
        Bull Am Coll Surg. 1983; 3: 3-6
        • Halluck R.S.
        • Krummel T.M.
        Computers and virtual reality for surgical education in the 21st century.
        Arch Surg. 2000; 135: 786-792
        • Andreatta P.B.
        • Woodrum D.T.
        • Birkmeyer J.D.
        • Yellamanchilli R.K.
        • Doherty G.M.
        • Gauger P.G.
        • et al.
        Laparoscopic skills are improved with LapMentor? Training: results of a randomized, double-blinded study.
        Ann Surg. 2006; 243: 854-863
        • Larsen C.R.
        • Sorensen J.L.
        • Grantcharov T.P.
        • Dalsgaard T.
        • Schouenborg L.
        • Ottosen C.
        • et al.
        Effect of virtual reality training on laparoscopic surgery: randomized controlled trial.
        BMJ. 2009; 338: b1802
        • Hamilton E.C.
        • Scott D.J.
        • Fleming J.B.
        • Rege R.V.
        • Laycock R.
        • Bergen P.C.
        • et al.
        Comparison of video trainer and virtual reality training systems on acquisition of laparoscopic skills.
        Surg Endosc. 2002; 16: 406-411