Doctors Massé, Godbout and Isler discuss how students in orthopedic surgery in Montreal, Canada will test their skills before entering the Operating Room (OR)

Vincent Massé MD, FRCSC Fellow, Véronique Godbout MD, FRCSC, MA Med.Ed., Dip. Sport Med. and Marc Isler MD, FRCSC, report.

Virtual simulation has long been used in the training of airline pilots on flight simulators to handle unexpected and challenging situations. These simulations have proven to be an effective way for pilots to learn from virtual experiences that would be difficult and dangerous to provide in the real world. In medical training, however, virtual simulation is a relatively new field. The most popular and recognized training simulators are at the present time minimally invasive surgery training simulators such as laparoscopy and endoscopy.

The Sim-K™ virtual simulator is the first orthopedic open surgery simulator and was presented for the first time at the American Academy of Orthopaedic Surgeons (AAOS) meeting last March 24 - 28 in Las Vegas.

According to a 2010 Centre for Disease Control (CDC) report, statistics show that total knee replacement (TKR) procedures were performed at an annual rate of more than 700,000 in the United States, while in Canada a 2012-2013 report from the Canadian Joint Replacement Registry showed that 57,700 procedures have taken place.

Virtual Reality simulation technology offers a stress free teaching tool that develops psychomotor skills to minimize error and enhance patient safety in the operating room.

The Sim-K™ Virtual Simulator

The Sim-K™ is a virtual reality simulator that has been designed for the training of medical students and orthopedic residents at the post graduate 1, 2, and 3 levels. The Sim-K™ simulator currently enables simulation training of orthopedic basic skills such as bone drilling and sawing, through a series of exercise modules leading to a full TKR procedure. The simulator enables our residents to experience real-time haptic feedback, a tactile feedback technology that takes advantage of the sense of touch by applying force, vibration, resistance or motion to the user. Generic mock-up surgical tools also allow students to handle and manipulate handheld drill and saw units in a risk-free training environment, thus helping them to develop their psychomotor skills.

The first and only virtual reality orthopedic open surgery simulator allows the practice of the total knee-replacement procedure that includes intervention-based tasks such as drilling and sawing on different shapes and materials, bones and articulations. The unit also allows tracking of total tools movement such as precision, orientation, amplitude, and depth. It also allows for the tracking of applied forces and completion time of tasks.

As surgeons who contributed to the development of the simulator, we devoted our efforts to create a virtual reality environment that precisely recreates the sound, force, and imaging of real-life orthopedic actions. For example, the unit can simulate potential complications such as sliding on the bone, misalignment, undesirable oversize burring or overshoot drilling, causing potential damage to arteries and nerves. The simulator is also equipped with built-in metrics data reports of performance and customized reporting features to track and evaluate a student’s performance. In this way, the simulator expands training possibilities in the field of open surgeries through a standardised and quality-assured training method. Medical educators and students are thus able to obtain a detailed evaluation of their individual learning in real time.

The simulator has obtained the European CE certification and complies with both American and Canadian standards. As part of a team of engineers and software programmers, we as medical surgeons focused on optimizing the tactile features of the simulator. For these reasons, the Sim-K is being sought as a pioneer in the field of open surgery. The software could eventually be modified to take into account different types of surgeries. Available in English only at the present time, it would be possible to expand the software’s spectrum to include procedures for open surgeries that are associated with trauma conditions. The company behind the development of the Sim-K, OSSim Technologies, has also received a mandate from a world-leading hospital to develop the software for spinal open surgery interventions.

There have been no completed clinical studies as yet but we intend to begin summer 2015. To date, tests have been performed in Montreal. The trials sought to optimize the sensorial aspects of the unit in order to more closely mirror the reality of the medical intervention. Our group at the Maisonneuve-Rosemont Hospital in Montreal plans to conduct further testing with students during summer 2015 in collaboration with CHUM (Centre Hospitalier Universitaire de Montréal) and plan on the participation of other major university teaching hospitals in Canada.


Approximately one hundred U.S. and Canadian university hospitals that have simulation facilities and medical faculties could eventually be the first centers to receive the Sim-K units, thus representing a critical entry potential for their deployment.

Medical students today have grown up in the field of computers and are adept at three-dimensional gaming activities. They are open to new technologies and welcome them during their years of training. The use of the virtual simulator can be learned fairly quickly. The unit is intuitive and user-friendly, though a student cannot advance to a higher level without resolving more basic simulation problems, not unlike many computer activities.

We expect the simulator to have a direct impact on students’ performances. With the Sim-K, residents can train and focus on their basic surgical skills effectively, in a controlled environment and as often as needed, without risk to patients and free of a hospital’s daily pressures and constraints. We believe the simulator will accelerate their learning process and significantly improve their skills and confidence while minimizing patient risk in the OR. This reduction of training time in the OR will benefit the resident MD, Faculty, and most importantly, the patient.

In addition to accelerating their training, we also expect that the simulator will help residents develop their cognitive processes, their dexterity, and their reflexes to better predict if a surgical situation is easy or difficult and react accordingly. This will improve both the resident and the Faculty’s confidence. Residents will thus be able to concentrate on the more difficult OR challenges they will encounter. For the practicing surgeon, the virtual simulator can result in time saved in the operating room as it helps residents start their training earlier by learning basic functions, face different types of situations, repeat over and over again certain procedures and improve their dexterity before entering the OR, making their time spent in the OR more efficient.

The virtual reality environment precisely recreates the sound, force and imaging of real-life actions. Image Credit: OSSim Technologies.
The virtual reality environment precisely recreates the sound, force and imaging of real-life actions. Image Credit: OSSim Technologies.


The implementation of the virtual simulator faces diverse challenges. Although the price of the simulator is competitive to arthroscopic simulators, once acquired, it is not certain the technology will be immediately embraced by the medical community. While simulators are becoming increasingly adopted as a means of training in diverse professions, the integration of simulation training in the curriculum still needs to be officially recognized.

Uniformity of training may also represent a challenge as organizations might use the simulator in different ways. Thus, training and practices will have to be standardized in order to be able to compare the performance of residents. Furthermore, updating the software will become important as the field of medicine and computer science is evolving rapidly.

Finally, research in the field of surgical skills evaluation will also present a challenge in assessing the resident’s progress, as well as gauging the value of the simulator as a teaching tool.

The Future

As medical educational training is currently focused on the optimization of clinical training, simulation of orthopedic procedures is becoming an increasingly important training and educational modality. We believe that the SIM-K will stimulate residency program directors to eventually incorporate virtual surgical simulation into the core curriculum of their residency programs. For example, in 2013, the Accreditation Council for Graduate Medical Education (ACGME) in the United States added a requirement that residency programs include a surgical-skills training curriculum as part of their program while the Canadian Royal College of Medicine encourages the use of simulation in the curriculum of medical students.

Indeed, demonstrating surgical skills through virtual simulation could become a requirement for certification and/or maintenance of certification for practicing surgeons. Training with virtual simulation should result in residents making fewer surgical errors and should shorten the time needed to perform surgical procedures at academic institutions and university teaching hospitals, where resident training slows the efficiency of the operating room. Proficiency-based training is likely to become a key standard in the near future.

From both a health and economic standpoint, it is hoped that virtual surgery simulation will be able to demonstrate a significant reduction of surgical complications and that the performance of future surgeons will be enhanced.

About the Authors

Dr. Vincent Massé MD, FRCSC Fellow is an orthopedic surgeon who specializes in the fields of hip and knee reconstruction at the Maisonneuve-Rosemont Hospital and the Santa Cabrini Hospital in Montréal (Quebec). Dr. Massé is a clinical teaching collaborator at the University of Montréal. A graduate from University of Montréal’s medical school, Dr. Massé obtained a Fellow in hip and knee arthroplasty from the Endo-Klinik (Hamburg, Germany), the University of British Columbia (Vancouver, Canada), and the University Claude-Bernard Lyon (Lyon, France).

Dr. Véronique Godbout MD, FRCSC, MA Med.Ed., Dip. Sport Med, is an orthopedic surgeon who specializes in medical education and sports medicine. Dr. Godbout practices at the CHUM Hospital (Centre hospitalier de l'Université de Montréal) in Montréal (Quebec). She became a Clinical Assistant Professor at the University of Montréal after doing her fellowship in arthroscopy and sports medicine in Calgary, Canada and a master’s degree in Medical Education at the University of Montréal. She implemented a simulation curriculum in a sports medicine arthroscopy rotation for residents in Montréal.

Dr. Marc Isler is an orthopedic surgeon who practices at the Maisonneuve-Rosemont Hospital, Sainte-Justine Hospital and Santa Cabrini Hospital in Montréal. During his career, Dr. Isler has long been involved in medical education at many levels, including Continuing Medical Education (CME). He has recently completed two mandates as director of the orthopedic residency program (POES) at the University of Montréal. He is presently an active member of the orthopedic surgery department at the Université de Montréal and a Fellow of the Royal College of Physicians and Surgeons of Canada.