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Virtual reality (VR) simulators have become widespread tools for training medical students and residents in medical schools. Students using VR simulators are provided with a 3D human model to observe the details by using multiple senses and they can participate in an environment that is similar to reality.
The aim of this study was to promote a new approach consisting of a shared and independent study platform for medical orthopedic students, to compare traditional tendon repair training with VR simulation of tendon repair, and to evaluate future applications of VR simulation in the academic medical field.
In this study, 121 participants were randomly allocated to VR or control groups. The participants in the VR group studied the tendon repair technique via the VR simulator, while the control group followed traditional tendon repair teaching methods. The final assessment for the medical students involved performing tendon repair with the “Kessler tendon repair with 2 interrupted tendon repair knots” (KS) method and the “Bunnell tendon repair with figure 8 tendon repair” (BS) method on a synthetic model. The operative performance was evaluated using the global rating scale.
Of the 121 participants, 117 participants finished the assessment and 4 participants were lost to follow-up. The overall performance (a total score of 35) of the VR group using the KS method and the BS method was significantly higher (
Our study shows that compared with the traditional tendon repair method, the VR simulator for learning tendon suturing resulted in a significant improvement of the medical students in the time in motion, flow of operation, and knowledge of the procedure. Therefore, VR simulator development in the future would most likely be beneficial for medical education and clinical practice.
Chinese Clinical Trial Registry ChiCTR2100046648; http://www.chictr.org.cn/hvshowproject.aspx?id=90180
The incidence of tendon rupture has been increasing owing to the increasing number of people participating in recreational and competitive sports [
In recent years, the use of virtual reality (VR) simulators has become widespread in medical school, and VR simulators are promoted for both medical students and resident training [
This study is a parallel-design randomized controlled trial comparing VR and control groups. This study was approved by the ethics committee of the First Affiliated Hospital of Jinan University and registered in the Chinese Clinical Trial Registry (Registry: ChiCTR2100046648). Information was collected from all participants after obtaining written informed consent in accordance with the Declaration of Helsinki. All participants were required to complete the final assessment, which was performing tendon repair on synthetic models with 2 different knots, that is, the “Kessler tendon repair with 2 interrupted tendon repair knots” and the “Bunnell tendon repair with figure 8 tendon repair” (KS and BS methods, respectively). The CONSORT checklist was used for this trial.
Senior medical students were the eligible participants in this study. They were required to complete the following fundamental courses before entering the randomized control trial: (1) human anatomy, (2) physiology, (3) biochemistry, (4) pathology, (5) pathophysiology, (6) diagnostics, (7) internal medicine, (8) orthopedics, (9) surgical probation, and (10) other professional basic clinical courses. This study excluded any participant who did not meet the above requirements. Written informed consent with a clearly stated study plan was given to all participants. The purpose of this trial was explained to the participants. After informed consent had been signed, we asked the medical students to perform tendon repair on synthetic simulations. A baseline score was given by an orthopedic specialist. Other baseline information, including gender, age, and grade point average, was collected from the medical school database.
All participants provided written, informed, and oral independently witnessed consent to participate in the research study. A random allocation sequence was generated using a random number table. A sequence was used to allocate the groups of participants to the VR and control groups. For the examination, the students performed tendon repair on a synthetic model. All participants were randomly assigned to one of the two groups. Participants in the VR group (n=61) learned the technique of tendon repair through the VR simulator method, whereas the control group (n=60) used the traditional tendon repair teaching method. The examiners were well-trained surgeons and unaffiliated with the medical school; they evaluated and assigned a score to each final product immediately without knowing the allocation list in a nonbiased manner during preintervention and postintervention assessments. In order to ensure the rigor of the examination, we included a short training session for the examiners. Training helps to clarify the examiner’s role, required behavior, review the marking guidance, marking assignment to standardize the exam, and encourage the consistency of the examiner's marking behavior. At the end of the training, examiners also did a marking exercise to scrutinize examiners' marking behavior. During the examination, medical students were asked not to tell the examiner which group they were assigned to (
CONSORT 2010 flow diagram showing the study process. VR: virtual reality.
The control group participants were required to participate in complete 8 hours of lectures and a 6-hour practical class in medical school for 2 weeks. The participants learned about traumatic orthopedic theory and the fundamentals of tendon repair during the lectures. They practiced tendon repair on synthetic models under the professor’s guidance. In the practice class, students were given a PowerPoint presentation, which provided illustrations, photographs, and step-by-step instructions. They were instructed to review the training material for 1 hour. The VR group participants were required to take the same course as the control group, except for the guided PowerPoint review part. Instead, they practiced with VR simulators (including the VR version and the personal computer [PC] version) for 1 hour in class. The medical students practiced under guidance with detailed instructions. The VR simulator focusses on every participant’s performance while performing tendon repair. The operation in the VR simulator is divided into practice and examination modes. Corresponding notes for each step during the practice mode were provided; however, no notes were provided for the examination mode (
Illustration of the trainings undertaken by each group.
Trainings | Virtual reality group | Control group |
Lectures (total 8 h) | ✓ | ✓ |
Practical class (total 6 h) | ✓ | ✓ |
Guided PowerPoint Review (within the practical class) |
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✓ |
Virtual reality + personal computer practice (within the practical class) | ✓ |
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Virtual reality + personal computer assessment (within the practical class) | ✓ |
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The VR simulator used in this study was created by Jinan University and the Department of Orthopedic Surgery and Sports Medicine Center [
(A) A medical student practicing with a virtual reality simulator; (B) the examination mode for the Kessler and Bunnell tendon suture modes.
Both the control and VR groups participated in the research study for 14 days. The results were calculated using the global rating scale. Seven dimensions were incorporated into the tool. The global rating scale shows different aspects of the operative performance. This technology was compared with the traditional teaching method by using the global rating scale for several aspects: (1) repair with respect to tissue, (2) time in motion, (3) instrument handling, (4) tendon repair skill, (5) flow of operation, (6) knowledge of procedure and final suture, and (7) qualitative and objective assessment of all tendon repair performances [
Data were analyzed using the SPSS 23.0 (IBM Corp) software package [
Between August 1, 2019, and August 12, 2020, 121 potential participants were assessed for study participation in the Medical School of Jinan University. Four participants from the control group dropped out of the program for personal reasons. All participants were required to undergo a final assessment on synthetic models, and the overall score sheet was used to calculate the results. This study analyzed all participants by using the global rating scale described above. The global rating scale baseline is shown for assessing tendon repair differences in the control and VR groups (
Posttraining scores on the global rating scale were used to assess tendon repair by the two groups.
With respect to tissue, no significant difference was found between the VR and control groups using the KS method (
Baseline characteristics.
Characteristics | Control group (n=56) | Virtual reality group (n=61) | |
Age (years), mean (SD) | 23.07 (0.97) | 22.93 (1.01) | .46 |
Gender (male), n (%) | 24 (43) | 31 (51) | .39 |
Grade point average, mean (SD) | 3.02 (0.54) | 3.19 (0.49) | .66 |
Kessler tendon repair with 2 interrupted tendon repair knots, median (IQR) | 8.00 (7-9) | 8.00 (7-9) | .13 |
Bunnell tendon repair with figure 8 tendon repair, median (IQR) | 8.00 (7-9) | 8.00 (7-9) | .25 |
Posttraining scores on the global rating scale to assess tendon repair.a
Repair method, aspects considered, global rating scale score (1: poor, 5: good) | Control group (n=56) | Virtual reality group (n=61) | |||||||||
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.22 | |||||||||
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1 | 0 (0) | 8 (13) |
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2 | 3 (5) | 41 (67) |
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3 | 52 (93) | 10 (16) |
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4 | 1 (2) | 2 (3) |
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5 | 0 (0) | 0 (0) |
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1 | 2 (4) | 0 (0) |
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2 | 14 (25) | 0 (0) |
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3 | 23 (41) | 20 (33) |
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4 | 17 (30) | 40 (66) |
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5 | 0 (0) | 1 (2) |
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.31 | |||||||||
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1 | 0 (0) | 0 (0) |
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2 | 8 (14) | 13 (21) |
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3 | 42 (75) | 43 (71) |
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4 | 6 (11) | 5 (8) |
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5 | 0 (0) | 0 (0) |
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.05 | |||||||||
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1 | 0 (0) | 0 (0) |
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2 | 11 (20) | 6 (10) |
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3 | 36 (64) | 38 (62) |
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4 | 9 (16) | 14 (23) |
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5 | 0 (0) | 3 (5) |
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1 | 0 (0) | 0 (0) |
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2 | 19 (34) | 0 (0) |
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3 | 33 (59) | 11 (18) |
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4 | 4 (7) | 49 (80) |
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5 | 0 (0) | 1 (2) |
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1 | 0 (0) | 0 (0) |
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2 | 15 (27) | 1 (2) |
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3 | 41 (73) | 1 (2) |
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4 | 0 (0) | 42 (69) |
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5 | 0 (0) | 17 (28) |
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.048 | |||||||||
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1 | 0 (0) | 0 (0) |
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2 | 3 (5) | 12 (20) |
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3 | 49 (88) | 24 (39) |
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4 | 3 (5) | 22 (36) |
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5 | 1 (2) | 3 (5) |
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Overall performance, median (range) | 20 (18-22) | 24 (21-29) |
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.21 | |||||||||
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1 | 0 (0) | 0 (0) |
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2 | 15 (27) | 23 (38) |
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3 | 41 (73) | 38 (62) |
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4 | 0 (0) | 0 (0) |
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5 | 0 (0) | 0 (0) |
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1 | 0 (0) | 0 (0) |
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2 | 15 (27) | 5 (8) |
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3 | 41 (73) | 32 (53) |
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4 | 0 (0) | 23 (74) |
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5 | 0 (0) | 1 (2) |
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.16 | |||||||||
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1 | 0 (0) | 0 (0) |
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2 | 8 (14) | 15 (25) |
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3 | 32 (57) | 33 (54) |
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4 | 16 (29) | 13(21) |
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5 | 0 (0) | 0 (0) |
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1 | 0 (0) | 0 (0) |
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2 | 17 (30) | 10 (16) |
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3 | 39 (70) | 30 (49) |
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4 | 0 (0) | 21 (34) |
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5 | 0 (0) | 0 (0) |
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1 | 0 (0) | 0 (0) |
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2 | 27 (48) | 1 (2) |
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3 | 25 (45) | 26 (43) |
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4 | 0 (0) | 28 (46) |
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5 | 4 (7) | 6 (10) |
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1 | 0 (0) | 0 (0) |
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2 | 21 (38) | 2 (3) |
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3 | 21 (38) | 11 (18) |
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4 | 14 (25) | 47 (77) |
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5 | 0 (0) | 1 (2) |
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1 | 0 (0) | 0 (0) |
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2 | 8 (14) | 11 (18) |
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3 | 41 (73) | 31 (51) |
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4 | 1 (2) | 9 (15) |
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5 | 6 (11) | 10 (16) |
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Overall performance, median (range) | 20.00 (16-23) | 23.00 (20-26) |
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aData in italics indicate significant differences. Both the methods were assessed using the 35-point global rating scale.
Several surgical trainings involve composite models, VR simulation, cognitive task analysis, and cadaver specimens. VR-simulated studies for surgical practice, such as laparoscopic, cardiovascular, and arthroscopic surgeries, can be found in the literature [
A VR simulator plays a major role in the medical field. The lack of medical practice and uneven distribution of medical resources in various regions has resulted in a decrease in clinical practice opportunities for medical students. In addition to tendon repair studies, the VR simulator can perform simulated surgery. Future surgeons can practice with a VR simulator until they are comfortable performing the operation. In addition, experienced surgeons can also study the simulation aspect of the VR simulator to learn and explore new surgical techniques or to discover other surgical options. The application of virtual technology in medicine, medical education, and clinical treatment will have a major impact on the medical system.
During the COVID-19 pandemic, the use of technology has become a popular topic in the medical education field. Tendon repair is a procedure that requires senior professional surgeons; therefore, medical students and junior doctors may not have sufficient practice to be able to perform suturing independently. A possible solution to this problem is that junior doctors practice using the VR simulator, thereby becoming more familiar with the procedure and more confident when performing it. The VR simulator can maximize a medical student’s efficiency with respect to mastering this technique. It has been proven that the VR simulator in a simulation laboratory rather than in an operating room is a better practice method than the traditional classroom study in terms of the flexibility of location [
The VR simulator can provide a realistic surgical scenario, thus allowing students to train for a particular skill continuously or to master any unfamiliar procedure. The findings of our study show that students learning via the VR simulator had significantly better scores than those learning via the traditional method with respect to the tendon repair technique (
A VR simulator can reduce the high costs of conducting animal or human trials [
Surgical training is different from other courses in medical school because students need to be exposed to nonstandard or beyond standard levels of teaching to help them understand how much they need to learn or improve. Studying with different methods can help students have a clear understanding of this curriculum. Surgical education departments have already purchased some effective training equipment that can help medical students achieve consistent and measurably high level of performance. Therefore, combining traditional and alternative teaching methods such as composite models and cognitive task analysis is necessary for the future [
VR simulators have good reusability. Once a VR simulator is established, the study will not be limited to that particular location or the number of students. The VR software can be freely downloaded by students from the internet. Therefore, medical students can study in any location and are not limited to the classroom or training room. Rather than taking turns practicing on subjects, students are able to practice together using the VR simulator. The 3 important advantages of students using VR simulators concurrently are as follows: (1) VR simulators allow students to perform the experiment together, (2) VR simulators allow the exchange of ideas or knowledge of a topic at the same level, and (3) VR simulators ensure that everyone is on schedule for the course.
VR simulators will be part of the future technology in the medical field, and medical students should be exposed to this technology as soon as possible to familiarize themselves with this method. In addition, feedback from students using a VR simulator can help improve the simulator, and further developments may be performed. The application of virtual technology in the field of medicine, medical education, and clinical treatment will have a major impact on health care and the development of the medical field and on the training of young doctors. Both software and hardware in the VR simulator can be flexibly configured according to the needs of teaching. In addition to tendon repair, VR simulators provide a set of virtual instruments that can be developed into different functions. The scope of virtual orthopedics is very wide and includes the fields of endoscopic protection, radiosurgery, microsurgery, and remote surgery. Moreover, a VR simulator is currently used in neurosurgery, eye, heart, plastic, and abdominal surgeries, and many other areas. Therefore, the widespread use of a VR simulator indicates that studying or performing surgery via a VR simulator is an effective method for completing this training task.
This study is the first to show that a VR simulator can also be applicable in medical schools and that it is a very effective method for medical students to enhance their learning through multiple repetitions by participating in a 360° VR environment. In addition, a VR simulator should be used in sections not only for complex surgeries but also in important presurgical sections, for example, tendon suturing. Studies have shown that medical students enjoy early exposure to clinical practice and perceive that it is valuable for future studies [
Despite the benefits of using VR simulators to train medical students, there are some challenges for medical schools to adopt this new approach in the future. For designing the program, the development corporation or the program writers who are not medical professionals have limited concepts or knowledge of the orthopedic procedure. This may lead to simulation results of nondetailed procedures, and medical students may miss the surgical details when practicing surgery in VR simulators. To overcome this obstacle, we had extensive discussions and we shared opinions back and forth between the medical school and the development team during the early period of establishing the VR simulator. It took at least a year to achieve an acceptable VR simulator for medical students. The other problem of VR simulators is the lack of validated score measures. Therefore, the final assessment was evaluated on synthetic models by using the global rating scale. Surgical training is a comprehensive process; therefore, medical students and surgeons may take years to master a surgical technique. The VR simulator is part of the comprehensive training but not the only training technique. Our findings show that the VR simulator is an effective method among the traditional teaching methods. We hope that future studies can focus on an effective VR simulator measurement scale or comparative evaluations between simulators.
The follow-up period in this study can only reflect the short-term effect of the VR simulator, which was a limitation of this study. The long-term effects on orthopedic specialists who practice on VR simulators could take years to evaluate.
Compared to the traditional tendon repair method, the VR simulator for learning tendon repair significantly improves medical students’ time in motion, suture skill, the flow of operation, and knowledge of the surgical procedure. Our paper sets an example for future VR simulator development for medical curricula.
Virtual reality simulator showing every step of the suturing process.
CONSORT-eHEALTH checklist (V 1.6.1).
Bunnell tendon repair with figure 8 tendon repair
Kessler tendon repair with 2 interrupted tendon repair knots
personal computer
virtual reality
TNM, JP, and WKM designed the study and wrote the manuscript. WKM and QH reviewed the risk of bias of the studies and the manuscript. JC and JL extracted the data from the studies. THS and JD interpreted the results. JL and ZZ supervised the entire study. The authors read and approved the final manuscript.
None declared.