In vivo biomechanical measurement and haptic simulation of portal placement procedure in shoulder arthroscopic surgery

A survey of 67 experienced orthopedic surgeons indicated that precise portal placement was the most important skill in arthroscopic surgery. However, none of the currently available virtual reality simulators include simulation / training in portal placement, including haptic feedback of the necessary puncture force. This study aimed to: (1) measure the in vivo force and stiffness during a portal placement procedure in an actual operating room and (2) implement active haptic simulation of a portal placement procedure using the measured in vivo data. We measured the force required for port placement and the stiffness of the joint capsule during portal placement procedures performed by an experienced arthroscopic surgeon. Based on the acquired mechanical property values, we developed a cable-driven active haptic simulator designed to train the portal placement skill and evaluated the validity of the simulated haptics. Ten patients diagnosed with rotator cuff tears were enrolled in this experiment. The maximum peak force and joint capsule stiffness during posterior portal placement procedures were 66.46 (±10.76N) and 2560.82(±252.92) N/m, respectively. We then designed an active haptic simulator using the acquired data. Our cable-driven mechanism structure had a friction force of 3.763 ± 0.341 N, less than 6% of the mean puncture force. Simulator performance was evaluated by comparing the target stiffness and force with the stiffness and force reproduced by the device. R-squared values were 0.998 for puncture force replication and 0.902 for stiffness replication, indicating that the in vivo data can be used to implement a realistic haptic simulator.