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Virtual Fracture Carving Improves Understanding of a Complex FractureA Randomized Controlled Study
Markian A. Pahuta, MD1; Emil H. Schemitsch, MD, FRCSC2; David Backstein, MD, MEd, FRCSC3; Steven Papp, MD, MSc, FRCSC4; Wade Gofton, MD, MEd, FRCSC4
1 University of Ottawa, 451 Smyth Road, Room 2044, Ottawa, ON K1H 8M5, Canada. E-mail address: mark.pahuta@gmail.com
2 St. Michael’s Hospital, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada. E-mail address: schemitsche@smh.ca
3 Mount Sinai Hospital, 600 University Avenue, Suite 476(D), Toronto, ON M5G 1X5, Canada. E-mail address: dbackstein@mtsinai.on.ca
4 The Ottawa Hospital-Civic Campus, 1053 Carling Avenue, Suites J157 (S.P.) and J159 (W.G.), Ottawa, ON K1Y 4E9, Canada. E-mail address for S. Papp: spapp@ottawahospital.on.ca. E-mail address for W. Gofton: wgofton@ottawahospital.on.ca
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  • Disclosure statement for author(s): PDF

Investigation performed at the University of Ottawa, Ottawa, Ontario, Canada

Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Dec 19;94(24):e182 1-7. doi: 10.2106/JBJS.K.00996
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The visual overlay technique for surgical planning is difficult to apply to spatially complex fractures. Virtual reality can be applied by virtual fracture carving to adapt the visual overlay technique to three-dimensional (3D) images. In this study, we evaluated whether virtual fracture carving is a useful exercise by performing two experiments comparing trainees’ understanding of a complex fracture with the application of either current preoperative techniques or the use of the Virtual-Fracture-Carving Simulator.


Forty-eight participants—senior medical students and residents in postgraduate year 1 (PGY1)—were asked to learn the anatomy of an associated both-column acetabular fracture. The participants were randomized into three groups: control, Sawbones, and virtual (Virtual-Fracture-Carving Simulator). The randomization protocol was stratified for sex and visuospatial ability. The measure of learning was a fracture line-drawing task evaluated for nineteen anatomic relationships.


The virtual group performed better than both the control and the Sawbones group, with an absolute difference in score of 22.7% (p = 0.0001) and 17.8% (p = 0.0026), respectively. There was no significant difference between the control and Sawbones groups. The virtual group drew fracture characteristics requiring a higher level of spatial understanding with greater accuracy.


The results of this study validate the concept behind the visual overlay planning technique—i.e., that thoughtful play promotes understanding of fracture anatomy. These results objectively demonstrate that the use of a Virtual-Fracture-Carving Simulator is feasible, and superior to conventional preoperative planning strategies in terms of quantity and quality of understanding of a spatially complex fracture.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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