This research presents a virtual reality simulator for total hip replacement surgery. The simulator supports a library of 3D hip stem models for different sizes and manufacturers. The 3D hip stems can be adjusted in size and shape by parametric software and sent for 3D printing. Biocompatible materials such as titanium enable the 3D printed stems to be directly implanted on patients. Currently surgical simulation for orthopaedic procedures is not as advanced as other surgical disciplines. As a result there are only limited training simulators available for orthopaedic surgery such as total hip replacement, hip resurfacing or knee replacement. This is demanding since 66,000 hip replacements are performed annually in the UK. One area which is neglected in VR orthopaedic simulation is the digital library generation of implants. Currently orthopaedic surgeons have limited choice in terms of an exact identification of implant specific to patient requirements. We conducted a literature review of orthopaedic training simulators which found no simulators catering for this [9]. Orthopaedic surgeons generally have a positive opinion for the use of virtual reality (VR) training systems. A survey amongst all orthopaedic surgeons in New Zealand found that 77% of qualified surgeons believe simulation is effective for practicing and learning surgical procedures [1]. A separate review from the American Academy of Orthopaedic Surgeons (AAOS) showed that over 80% agreed that surgical skills simulations should become a required part of orthopaedic training, based on views from 185 program directors and 4549 residents. There was a strong agreement that simulation technology should be a required component of orthopaedic resident training [2]. The hip replacement procedure has been considered as the most successful and influential orthopaedic surgery of the twentieth century. Currently over 66,000 total hip replacements (THR) are performed each year in England and Wales by the National Health Service (NHS) and around 75,000 hip fractures are treated each year in the UK. Knee arthroscopy has increased 49% from 1996–2006 and now over 1 million are performed each year [3]. Each year there are an increasing number of orthopaedic procedures due to the aging population. Currently 247,000 hip fractures occur yearly in the United States, with the majority occurring in the population over 45 years old [4]. The incidence of hip fracture is also on the rise, partly due to the aging population, with over half a million hip fractures annually expected by 2040. The cost of these fractures is also expected to rise from $7 billion per year [4], to nearly $16 billion per year by 2040 [5]. Each hip fracture is estimated at costing between $39,555 and $40,600 in the first year after surgery [6]. Hip fractures have the highest cost of any orthopaedic procedure after surgery, and also incur $11,241 each year following surgery in extra health costs. Due to increased life expectancy, worldwide by 2050, it is projected that 6.26 million hip fractures will occur annually [7]. A paradigm shift is underway toward use of surgical training simulations [8]. The conventional master-apprentice learning model for surgical training of ‘see one, do one, teach one’ has recently been seen as inefficient. Due to orthopaedics being heavily dependent on technical skill, orthopaedic VR simulation holds potential to have great impact for improving surgical skill. The transition to VR simulation is relatively new compared to cadaver training which has been the gold standard for several centuries.

Computer-Aided techniques have been deployed more commonly in recent years to assist with surgical procedures, particularly in the case of minimally invasive surgeries. Arthroscopy, as one of the most prevailing minimally invasive surgical procedures, increases surgical complexity due to the loss of joint visibility, but has many advantages. More obstacles are encountered during hip arthroscopy, given the tight socket-joint hip anatomy. Therefore, computer-aided techniques could be used to ease such difficulties during hip arthroscopy.

Rotator cuff tears can be the source of significant morbidity. Impingement syndrome involving repetitive and prolonged mechanical irritation of the rotator cuff against the roof of the shoulder creates a progression of disease. Chronic tendon inflammation can lead to structural loss of integrity, leading to partial tears, and if left unchecked, full-thickness tears. Currently, the surgeon has the ability to repair full-thickness tears using minimally invasive techniques. However, the persistent tear rate after repair is remarkably high, more than 50% in some studies. One surgical goal is to alter progression of disease, and repair partial-thickness tears, for example. Another goal is to optimize the healing environment with the repair construct itself, accounting for biomechanical considerations. When using an arthroscopic approach, the challenges for treating partial- versus full-thickness tears varies significantly given anatomic restrictions—particularly, during repair of partial-thickness tears, the surgeon is “blind” for portions of the procedure as the arthroscope is typically placed intra-articularly, while instruments are passed from above the tendon, extra-articularly. Ideally, new technologies can be developed to optimize rotator cuff repair and healing in this setting.

Hip Arthroscopy is the most rapidly growing field in Orthopaedic Surgery. The volume of hip arthroscopy has tripled since 2003. Yet, despite the rapid recent growth, it is felt that only 10% of problems that can be treated with hip arthroscopy are currently being done so. The reasons for this are multiple — lack of recognition of problems in the hip by those not experienced with non-arthritic hip problems, insufficient numbers of surgeons trained to do hip arthroscopy, and, not unimportantly, the difficulty of performing hip arthroscopy. One of the most common underlying problems affecting individuals with non-arthritic hip pain is femoroacetabular impingement (FAI). FAI was first described by Ganz in the Swiss literature in 1995, and did not make it into the English literature until 1999. Due to its very recent identification, acceptance of this problem and dissemination to clinicians has resulted in a relatively low number of clinicians being aware of this problem.

Ligament injuries in the knee are a common cause of disability in the active population. The advent of arthroscopy and arthroscopic surgical techniques has changed our ability to diagnose and treat these injuries. Arthroscopy has become the gold standard for diagnosis of intra-articular ligament injuries, as well as meniscal and articular cartilage pathology. It combines optimal visualization and the ability to manipulate tissue under anesthesia to best understand the degree of ligament injury and knee instability. Arthroscopy has also evolved into the primary means for the surgical treatment of injuries to intra-articular ligaments, articular cartilage, and meniscus.

Sports medicine/joint preservation represents one of the fastest growing segments of orthopedic markets. It is estimated that the frequency of rotator cuff repair alone is increasing between 10 and 20% per year. Similar to the ongoing evolution in other medical specialties (cardiology, general surgery), an increasing number of joint preservation procedures are transitioning to less invasive techniques. However, there are significant unmet needs as soft tissue repair transitions from invasive open surgical techniques to less invasive arthroscopic methods.

Key Questions — Learning Objectives: A. What has lead to the historical progress with rotator cuff repairs? B. Is there basic science supporting an “all-arthroscopic” rotator cuff repair? C. What are the future technologies that are promising to enhance rotator cuff healing?

A transosseous-equivalent rotator cuff repair has shown improved biomechanical characteristics compared to other more cumbersome arthroscopic double row repairs. However, the transosseous equivalent repair, which requires knot tying, still can be challenging when tensioning the repair construct. We hypothesized that a knotless dual row loop repair has similar biomechanical characteristics to the transosseous-equivalent rotator cuff repair. Therefore, the objective of this study was to quantify and compare the biomechanical characteristics of a knotless double row repair and transosseous equivalent rotator cuff repair using matched pair shoulders.