Augmented reality enhanced physical simulation for femoral nailing training

Current femoral nailing simulators face a trade-off between delivering procedural guidance and realistic haptic feedback. This study aimed to address this limitation by developing and evaluating an augmented reality (AR)-enhanced physical simulator that combines real surgical instruments with AR-based visualization. The system provides spatial feedback on fluoroscopic imaging orientation and implant placement within hidden anatomical structures, supporting self-directed learning.

A hybrid simulator integrating a synthetic femur, real surgical instruments, and an AR interface on the Apple Vision Pro was developed. The AR application introduces users to fluoroscopic imaging and implant placement-covering nail insertion and alignment. After completing this AR-guided phase, 25 participants (6 experts and 19 non-experts) performed three unguided simulation runs followed by one retention session. Performance metrics included task completion time, number of simulated fluoroscopic images, and implant placement accuracy.

Data from 23 participants were analyzed. Task completion time decreased across simulation runs (insertion: -47.1%; alignment: -57.4%) and remained stable during retention. The number of simulated fluoroscopic images declined (insertion: -45.6%; alignment: -49.2%). Implant placement accuracy remained stable. Experts consistently performed faster than non-experts, with performance differences decreasing across simulation runs.

The AR-enhanced physical simulator led to clear learning effects in procedural efficiency and radiographic handling while maintaining consistent implant accuracy. These findings support AR as a valuable tool to enhance accessibility, spatial learning, and realism in simulation-based surgical training, representing a further step in the ongoing shift toward simulation-based surgical training.