# A Review of Training and Guidance Systems in Medical Surgery
## 3 Methods
### Synthesis of the Selected Works
#### 3.8.6 Orthopedics  
Simulations in this area cover standard procedures. For example, the investigation of [PERSON] et al. used real patient computed tomography (CT) scans for pedicle screw fixation in spinal surgery [86]. An in-house CA software made by the authors in their previous research was used [122]. These CT scans, in collaboration with the software, are used to produce real-time fluoroscopic images of the lumbar spine. This approach was applied to generate guidance in the virtual operation. Results in [PERSON] et al. simulator are based on surgery time, the accuracy of pedicle screw insertion, and the number of exposures made by the user to complete the procedure. In the physical application area, [PERSON] et al. proceed to perform a shoulder girdle and brachial plexus surgery using robot-assisted procedures [87]. [PERSON] et al. used this approach using the Intuitive Surgical da Vinci Si. Their goal was to create a minimally invasive technique that could allow earlier exploration and possible repair within eight days of the trauma. The experiment was done at the Intuitive Surgical laboratory. Four skin incisions were made during this operation. Two of them were used to introduce robotic arms that carried suitable surgical instruments. The other two incisions were created to add a dual endoscopic 3D HD vision camera. Dissections were made with the da Vinci Si robot, and results obtained could support that the endoscopic supraclavicular brachial plexus palsy is feasible using robot-assisted surgeries. Another approach for CA surgeries is the one proposed by [PERSON] et al. [88]. They evaluated if a CA system could act as an intraoperative ruler in high tibial osteotomy (HTO). Fifty-one patients with arthritis were treated. They used the Tomofix Osteotomy System guide technique, developed by Synthes, in collaboration with the VectorVision Osteotomy module created by BrainLAB. In this type of surgery, minimally invasive units were placed in the medial cortex of the tibia and the ventral medial or the ventral lateral side of the femur. By using anatomical landmarks, the system calculates all the information that surgeons need for this operation. A screen is used to show the leg and the alignment parameters. Patients that were treated using this approach showed precise intraoperative limb alignment. Therefore, the authors concluded that CA HTO provides better results than using current pre-operative plans. [PERSON] et al. also tested the feasibility and accuracy of CA systems in pelvic screw placement [89]. They used the BrainLAB VectorVision navigation system and the ARCADIS Orbic intraoperative 3D imaging system created by Siemens Medical Solutions. Tests were done on five human cadavers preserved using [PERSON]'s solution. Both software was used to help surgeons place forty screws into the first and second vertebra. Accuracy tests were done after the operation via standardized CT protocols by two independent radiologists. Malpositioning was defined as any screw penetration of the bony cortices, regardless of the direction. The CA system obtained positive results; in other words, complete and successful interior tidal screw positioning in all the different pelvic regions was achieved with a zero percent misplacement rate. Approaches covered by [PERSON] et al. [87] [PERSON] et al. [88] and [PERSON] et al. [89] could confirm the need for CA or robot-assisted technologies in surgeries. These systems should be considered high-value resources because they can enhance performance by reducing malpositioning or errors during medical operations. Additionally, they could be considered a way to provide security when less experienced surgeons are the ones that perform the task in operating rooms. [PERSON] et al. developed an orthopedic training simulator to perform Less Invasive Stabilization System (LISS) plating surgery [47]. The simulator can use both virtual reality and haptic feedback features. The simulator can be applied using an HTC Vive set up for virtual immersion.