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Mr Tony Andrade is a consultant orthopaedic, hip and knee surgeon with a special interest in hip preservation surgery. He has pioneered and developed internationally recognised techniques and training programmes in hip preservation surgery and hip and knee joint replacements. He is currently president of ISHA — The Hip Preservation Society — an international society which has been using Proximie to facilitate remote teaching since 2018.

ISHA’s link with Proximie dates back to a time before COVID; we had been making use of it as a remote teaching platform for a while before there was suddenly an urgent need to deal innovatively with travel restrictions. As a society with members from all over the world, we saw it as a very useful tool that would enable us to set up virtual education events to share knowledge across borders.

I saw a post on LinkedIn by Proximie founder Dr Nadine Hachach-Haram back in 2018, and I reached out to her to see how we might be able to establish a link between Proximie and our society. We subsequently set up Proximie at our institution, such that we were able to start some broadcasts and recordings.

“For me, that was the great appeal of Proximie: the ability to teach and interact remotely.”

Historically, the way for surgeons to learn more specialist techniques would be to visit other surgeons in their hospitals. You’d have to travel to other surgeons — who could be anywhere in the world — and spend time with them to understand how they perform their techniques and how that might then benefit patients. Not only is that time consuming, but it’s also very costly — both in terms of travel expenses and in terms of taking time out from your own practice. So, one of the great attractions of Proximie was the ability to interface with surgeons who might be on the other side of the world, while preserving that experience of learning from them in real time.

Because of our role as a society, it means we can then teach other surgeons remotely. Somebody who wants to learn a technique might initially read about it, they might learn about it on a course, they might see a video about the technique, and then typically in the past they would go and spend some time with an expert in that technique. Proximie, however, allows remote mentoring so that initially the learner would be able to remotely watch the expert surgeon use that technique, and then eventually the learner can set up some cases to do themselves, while having the expert remotely guide them through the procedure to help ensure an excellent outcome for the patient.

“The way it aids the surgical learning process is extremely exciting.”

The fact that we’ve been using Proximie since the relatively early stages of its development means that we have seen the platform’s evolution while evolving alongside it. As a society we have had a number of events using Proximie, and initially it was for live broadcasts of a surgeon operating whilst moderators were using Proximie to annotate on the screen; an augmented reality offering that is instrumental in terms of being able to maximise the learning potential for participants.

We went from that relatively simple type of event to a point where ISHA now has a regular virtual education programme that includes webinars, symposia and live surgery events — all facilitated by Proximie.

Early on it was only possible to have two simultaneous streams, but now you can have up to four at once. You really get a sense of the benefit of multiple streams when you’re talking about arthroscopic (keyhole) surgery, and you’re looking through a telescope into a joint. There’s a lot of the work that actually happens within the joint, and that’s what you can see on the camera feed — but at the same time there’s a certain amount of work that’s happening outside the body, and that’s something you can then see on another stream. For instance, you could be setting up the patient in an operating theatre, and you would see the set up on the outside of the body on one screen that shows where you’ll be making your incisions to gain access to the joint and what instruments you’ll be using. From the other stream you can see what’s going on inside; how the tools look and what job they’re doing internally, and in yet another stream you can see the image from fluoroscopy used to aid the access to the hip joint. Using all these streams together helps to maximise the experience.

We broadcast a live labral reconstruction just recently which made excellent use of the four screens. Over 500 people registered for the event from a total of 57 countries, including the Cayman Islands. While you have someone in the operating theatre performing surgery, Proximie allows moderators to annotate on each of the four screens seen by participants. The moderators can draw arrows or circles, or anything to help highlight things that the surgeon is doing during the procedure. The moderator can point to certain areas and say for example “this is the labrum”, “this is the articular surface of the acetabulum”, “this is where the suture is going to go”. These annotations help participants understand what’s going on, providing an augmented reality experience so they can see visually what is happening and adding to how the surgeon is verbally explaining it. It just all helps to clarify what’s going on.

ISHA has always had an annual scientific meeting once a year; when we would meet in person, the venue would change every year and we’ve met pretty much all over the world as we are an international society. That was really the highlight of the year, where all our members came together under one roof to share knowledge, share experiences and learn from one another. With COVID it became very clear that we weren’t going to be able to hold the in person yearly meeting in October 2020, so we needed to provide an educational offering to our membership as a replacement; we set up this virtual education programme, which in part was made possible with the assistance of Proximie, so that we could hold webinars and symposia where the augmented reality functionality helped to maximise the learning experience.

Some of our associate members, who are surgeons in training, have also been very excited about the potential of going through a mentorship that would then ultimately lead to them being able to operate in their hospitals with a remote mentor guiding them — something that people have commented on as being very reassuring for them during the learning process. That’s something that will continue to evolve.

On a personal level, I’ve had fellows who worked under me who have now progressed to consultant status and are surgeons in their own right at their own hospitals, and they want to be able to set up the facility where I can remotely guide them while they are performing procedures that are an extension of what they already do.

“The augmented reality packages offered by Proximie have evolved quite a bit since we first started using it, and it now provides an experience as close to being in the room as is currently possible.”

There is potential for this technology to benefit the broader specialty of surgery or medicine as a whole, because Proximie has uses in pretty much every specialty; I know of colleagues in ENT surgery, colorectal surgery and cardiology who are all interested in using it — and some of them already have.

I believe we’re going to see it increasingly used in a wide range of applications across the whole of medicine. It has been very exciting to watch it evolve into what it is today and for ISHA to have been part of its journey.