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Immersive virtual reality provides an opportunity for remote surgeon learning and collaboration. Multiple surgeons are able to perform operations in a virtual environment while avoiding costly, carbon-emitting travel.
Source: Precision OS Technology, Vancouver, British Columbia, Canada

AAOS Now

Published 5/1/2020
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Ryan Lohre, MD; Bernard F. Morrey, MD; Danny P. Goel, MD, MSc, FRCSC

Immersive Technologies Offer Short- and Long-term Value

Virtual reality programs can offset travel restrictions and reduce CO2

The global orthopaedic community has seen profound changes in training and practice with the restrictions imposed during the COVID-19 pandemic. Surgical volume, practice management, and healthcare economics will see continued downstream effects, and travel restrictions have prevented surgeons from attending courses and conferences.

With reduced global travel, there have been significant reductions in environmental pollutants. Carbon dioxide (CO2), the compound most prominently linked to climate change, has dropped by more than 10 percent in Manhattan, N.Y. In China, carbon emissions have dropped by as much as 25 percent due to decreased industrial activity and supply chain disruptions. Contributing to the overall reduction in carbon emissions is reduced international aviation. Total flight volume in the United States has dropped by 87.1 percent compared to last year. This is important because reducing global CO2 emissions has been identified as the primary means of preventing catastrophic climate changes.

Within the current restrictions, it is important to recognize our normal extent of travel and the effects our aviation practices have on climate change. Combined domestic and international aviation is estimated to contribute 5 percent of global CO2 emissions. Prominent organizations such as the Tyndall Centre for Climate Change Research have observed that a major contributor to CO2 emissions is travel. There are no data concerning orthopaedic surgeons’ amount of aviation and its contribution to CO2 emissions. However, as health advocates, we should acknowledge our environmental impact and attempt reductions.

The COVID-19 pandemic has informed us of the value of surgeon education and meeting structure. Both national and international meetings (including the AAOS 2020 Annual Meeting) have been canceled and partially converted to virtual conferences. Professional society meetings such as the Arthroscopy Association of North America, American Association of Hip and Knee Surgeons, and Canadian Orthopaedic Association have similarly been canceled. The AO Foundation, with more than 800 courses and 50,000 participants per year, also transitioned to online courses for the foreseeable future.

To adapt to the current restrictions, surgeons and training programs have turned to virtual learning methods. Immersive virtual reality (iVR) has been used by training programs at the Mayo Clinic and University of Connecticut to prevent skill degradation for trainees during restrictions.

The novel methods of learning and communication leveraged during the COVID-19 pandemic have unique properties that facilitate reductions in carbon emissions from travel activities. Concern has been raised that upon return to normalcy, society will have missed an opportunity to “reset the dial” on perspectives such as climate change. We should learn from our experiences during our current restrictions to improve our behaviors in the future. A novel, cost-effective, and climate-conscious way of doing this could be incorporating continued virtual meetings and iVR simulations in orthopaedics.

Fig. 1 A flight map production of 40 countries from around the world attending the AAOS 2019 Annual Meeting in Las Vegas
Source: Great Circle Mapper. Available at: http://gc.kls2.com. Accessed April 30, 2020.
Fig. 2 Immersive virtual reality provides an opportunity for remote surgeon learning and collaboration. Multiple surgeons are able to perform operations in a virtual environment while avoiding costly, carbon-emitting travel.
Source: Precision OS Technology, Vancouver, British Columbia, Canada

Orthopaedic-related air travel

The average yearly number of courses attended by orthopaedic surgeons has not been quantified. Through discussion, we have identified that surgeons in North America likely attend four to five courses per year. An international needs analysis of 3,790 orthopaedic surgeons identified courses and conferences as their preferred, primary means of continuing medical education (CME).

Similarly, our polling of senior orthopaedic surgery residents at our institution identified a range of 20 to 50 flights in their final years of training to attend conferences, courses, elective rotations, and fellowship interviews.

Average per capita CO2 emissions in the United States and Canada are estimated at 14.95 and 14.91 metric tons per year, respectively—considerably higher than the global average of 4.35 metric tons per person per year. Approximately eight return flights from Los Angeles to New York would produce the global average per person. It is not unreasonable to assume that many orthopaedic surgeons reach that number yearly from flights to attend meetings alone.

A search of available international orthopaedic conferences encompassing multiple subspecialties revealed approximately 40 available global meetings in 2019. If we consider 15 academic orthopaedic surgeons as representative examples of traveling to a meeting in a major U.S. city, the carbon burden produced by those attending orthopaedic surgeons can be inferred with the International Civil Aviation Organization commercial aviation carbon emissions calculator.

Total passenger CO2 emissions by those 15 surgeons would be 6.44 metric tons, equivalent to 1.5 passenger vehicles driven for an entire year, or more than 7,000 pounds of coal burned. Some larger conferences have more than 11,000 attendees—with this amount, not accounting for ground travel and assuming return flights, the total CO2 emissions would be more than 4.4 million metric tons. This is equivalent to driving nearly 1,000 passenger vehicles for a year, burning nearly five million pounds of coal, or powering nearly 750,000 homes with electricity for a year. Fig. 1 shows a flight map of all major airports from 40 countries of surgeon attendees to the AAOS 2019 Annual Meeting.

A place for virtual conferencing and education

It is imperative that we continue to advance our skills and needs, but how do we augment that experience while remaining conscious of the global burden of emissions? One conceivable method is to leverage the technological experience gained during the COVID-19 pandemic. The current alterations in learning and practice structure have led to incorporation of virtual meetings, virtual patient visits, and virtual educational opportunities.

Virtual meeting platforms have replaced in-person meeting structures. The meetings have been particularly effective for training sessions, allowing for a greater number of attendees and scheduling times. Furthermore, experts from other centers have been more frequently invited for case discussions.

The Digital Orthopaedics Conference San Francisco meeting, virtually organized by Stefano Bini, MD, and AAOS, is a novel, adaptive incorporation of virtual conferencing. Virtual paper presentations have been presented as electronic posters in this format.

Within the context of travel restrictions and elective surgery cancellations, we have identified the concern of skill decay. With periods of surgical inactivity, technical ability and knowledge may reduce, and they can require extended periods of time to reacquire. iVR has reached new levels of realism, owing to computing power. The current iVR systems combine entertainment industry-level audiovisuals with sense-of-touch feedback to provide a unique multisensory user experience. The technology is distinguishable from the virtual meetings that have gained popularity. Online virtual meeting platforms such as Zoom, Google Meet, Apple FaceTime, and Skype allow for physically distanced meetings through general personal computers and handheld devices.

Other platforms have additionally been used for virtual patient meetings. iVR requires consumer-grade VR systems such as Oculus Quest. The combined head-mounted display and position-tracked controllers used in the iVR systems allow for three-dimensional simulated operating room (OR) environments and far greater interaction than virtual meeting platforms. iVR products such as Precision OS, Fundamental Surgery, and Osso VR combined with virtual meetings can provide a viable option for continued training and CME during the COVID-19 pandemic. The virtual framework can similarly be utilized after the pandemic to reduce travel.

iVR technology provides access to virtual ORs, complete with interactive patients, so that surgeons can practice complex surgical procedures. iVR technology provides remote collaboration between mentors and mentees. The availability of iVR and reduced travel requirements can increase total reach of courses or conferences. For example, surgeons abroad and those from low- to middle-income countries, where international flight can be exceedingly time-consuming and costly, may prefer this learning method.

Expert surgeons can participate in virtual, collaborative ORs similar to technical courses and practice techniques or new implants. iVR systems are available for purchase and come equipped with software providing multiple training scenarios, such as anterior approach to hip arthroplasty, reverse shoulder arthroplasty, or revision total knee arthroplasty. Immersive multiplayer operative interactions can be coordinated through the user interface in the iVR system software. Fig. 2 shows a representative example of a virtual OR for purposes of learning complex orthopaedic skills. How these immersive environments provide value has been previously described by the senior author.

Future considerations

Conferences such as the AAOS Annual Meeting provide exceptional delivery of novel concepts and an unparalleled collaborative environment. Similarly, courses such as those provided by the AO Foundation are fundamental experiences in orthopaedic education. Such enjoyable CME formats should be continually promoted for the international orthopaedic community. The learning formats would, however, benefit from the expanded reach offered by virtual conferences and iVR technology.

Replicable kinesthetic learning with expert interaction through remote, multiplayer iVR features will continue to provide conference and course experiences remotely and may help surgeons maintain skills. Virtual meetings provide expanded interaction opportunities for remote surgeons or an ability to meet more frequently. Organizations providing CME could produce virtual conferences combining virtual video meetings with iVR multiplayer operative experiences. This would require individual or institutional availability of iVR systems per each participant. This framework of CME and orthopaedic community participation would mitigate CO2 emissions from travel, while providing a robust and extended collaborative learning environment beyond in-person meetings alone.

Practice for tens of thousands of orthopaedic surgeons and trainees abruptly changed due to the novel SARS-CoV-2 virus. As a global community of surgeons, we must recognize our contributions to the growing climate crisis. We have the potential to significantly reduce our carbon footprint by traveling selectively and incorporating virtual meetings and iVR into our practice. The recent COVID-19 pandemic has forced us all to reconsider how we communicate and train in effective ways. These lessons should be carried forward to augment course attendance and reduce our carbon footprint.

Ryan Lohre, MD, is a senior orthopaedic surgery resident in the Department of Orthopaedics at the University of British Columbia (UBC) in Vancouver, Canada.

Bernard F. Morrey, MD, is professor of orthopaedic surgery at the University of Texas Health Science Center in San Antonio.

Danny P. Goel, MD, MSc, FRCSC, is a clinical associate professor in the Department of Orthopaedics at UBC. He is also chief executive officer and founder of Precision OS Technology, an immersive medical education software company.

References
McGrath M: Coronavirus: Air Pollution and CO2 Fall Rapidly as Virus Spreads. Available at: www.bbc.com/news/science-environment-51944780. Accessed April 30, 2020.

Stone M: Carbon Emissions Are Falling Sharply Due to Coronavirus. But Not for Long. Available at: www.nationalgeographic.com/science/2020/04/coronavirus-causing-carbon-emissions-to-fall-but-not-for-long/. Accessed April 30, 2020.

Reed D: Airlines Can’t Shrink Fast Enough to Keep up with the Unprecedented Collapse in Global Travel Demand. Available at: www.forbes.com/sites/danielreed/2020/03/26/airlines-cant-shrink-fast-enough-to-keep-up-with-the-unprecedented-collapse-in-global-travel-demand/#632e353a6653. Accessed April 30, 2020.

United Nations Framework Convention on Climate Change: The Paris Agreement. Available at: https://unfccc.int/process-and-meetings/the-paris-agreement/the-paris-agreement. Accessed April 30, 2020.

Azar C, Johansson D: Valuing the non-CO2 climate impacts of aviation. Clim Change 2012;111:559-79.

Le Quéré C, Capstick S, Corner A, et al: Towards a Culture of Low-carbon Research for the 21st Century. Available at: https://tyndall.ac.uk/sites/default/files/publications/twp161.pdf. Accessed April 30, 2020.

Royal College of Physicians and Surgeons of Canada: CANMEDS 2015 Physician Competency Framework. Available at: http://canmeds.royalcollege.ca/en/framework. Accessed April 30, 2020.

Goel DP, Warner JP, Morrey BF, et al: Mitigating surgical skill decay and patient risk during the COVID-19 pandemic. J Bone Joint Surg Am 2020 [pending publication].

Schwartz AM, Wilson J, Boden SD, et al: Managing resident workforce and education during the COVID-19 pandemic: evolving strategies and lessons learned. J Bone Joint Surg Am. 2020 [pending publication].

Buckley R, Brink P: International needs analysis in orthopaedic trauma for practising surgeons with a 3-year review of resulting actions. J Eur C 2017;6:1398555.

Statista: The Global Disparity in Carbon Footprints. Available at: www.statista.com/chart/16292/per-capita-co2-emissions-of-the-largest-economies/. Accessed April 30, 2020.

International Civil Aviation Organization: ICAO Carbon Emissions Calculator Methodology Version 10. Available at: www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=2ahUKEwiIkp7u6ZDpAhUynOAKHXENC_0QFjAAegQIAxAC&url=https%3A%2F%2Fwww.icao.int%2Fenvironmental-protection%2FCarbonOffset%2FDocuments%2FMethodology%2520ICAO%2520Carbon%2520Calculator_v10-2017.pdf&usg=AOvVaw0-0GgDMZUTIBdnDL1n0P5H. Accessed April 30, 2020.

International Civil Aviation Organization: About ICAO. Available at: www.icao.int/about-icao/Pages/default.aspx. Accessed April 30, 2020.

Environmental Protection Agency: Greenhouse Gas Equivalencies Calculator. Available at: www.epa.gov/energy/greenhouse-gas-equivalencies-calculator. Accessed April 30, 2020.

INFOCUS Marketing. AAOS 2020 attendee mailing list. 2020.

Liang ZC, Wang W, Murphy D, et al: Novel coronavirus and orthopaedic surgery. J Bone Joint Surg Am 2020;e1:1-5.

Digital Orthopaedics Conference San Francisco: Virtual Summit. Available at: www.docsf.health/page/1511108/covid-19-virtual-summit. Accessed April 30, 2020.

Arthur WJ, Day EA: Skill decay: the science and practice of mitigating skill loss and enhancing retention. In: Ward P, Schraagen JM, Gore J, Roth EM, eds. The Oxford Handbook of Expertise. Oxford, England: Oxford University Press; 2019.

Lohre R, Bois A, Athwal GS, et al: Improved complex skill acquisition by immersive virtual reality training: a randomized controlled trial. J Bone Joint Surg Am. 2020;102:e26.

Bonasio A: Precision OS Launches Multiplayer Tool for VR Surgical Training. Available at: https://vrscout.com/news/precision-os-multiplayer-surgical-training/. Accessed April 30, 2020.