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Role of Simulation in Arthroscopy Training

Madan, Simerjit Singh MS; Pai, Dinker R. MS, FRCS

doi: 10.1097/SIH.0b013e3182a86165
Review Article

Summary Statement Arthroscopy uses a completely different skill set compared with open orthopedic surgery. Hitherto, arthroscopy had not been given enough emphasis in the core orthopedic curricula. Simulation has been seen as an excellent way to teach the skills required in arthroscopy. The simulators used for arthroscopy training can be broadly classified into physical simulators such as cadavers, animals, models and box trainers, virtual-reality simulators, and hybrid simulators that combine virtual-reality simulation with physical components that allow real tactile feedback. The advantages and disadvantages of each of these types have been described in this article. The factors that determine skill acquisition using these simulators have been highlighted. In conclusion, simulation seems to be a valuable tool for arthroscopy training, although further studies are needed to state whether this translates into better operative skill on real patients.

From the Departments of Orthopaedics (S.S.M.) and Surgery (D.R.P.), Melaka Manipal Medical College, Jalan Batu Hampar, Bukit Baru, Melaka, Malaysia.

Reprints: Simerjit Singh Madan, MS, Department of Orthopaedics, Melaka Manipal Medical College, Jalan Batu Hampar, Bukit Baru, Melaka, Malaysia (e-mail:

Both the authors contributed to the drafting of the manuscript and critical revision for important intellectual content and are in agreement with the content of the manuscript.

The authors disclose no conflicts of interest.

Medical simulation, although still in its infancy as compared with simulation in engineering or aviation, has progressed by leaps and bounds during the last 2 decades. The reasons for this progress, to name a few, are the reduced resident work hours, increasing patient demands, and the increased stress on patient safety as well as on optimizing patient throughput. Live patient experience especially in developing countries is often gained at risk to patients because of inadequate supervision owing to manpower shortage and lack of regulations. Simulation helps in reducing errors by allowing practice of basic and complex procedures in a safe environment without any risk to the patients and the trainee surgeons.1 As Ziv et al2 stated, “Patients are to be protected whenever possible and are not training commodities.” It is also not acceptable to make mistakes on patients when alternatives are available.3 However, it is always a difficult balancing act to fulfill one’s commitment to train residents on the one hand with not putting patients to harm at the same time on the other. It is therefore important to make sure that the trainee surgeon has the basic skill set, which allows him to operate safely under supervision, before he touches an actual patient. Improvement in simulation technology and ease of its availability has gone hand in hand with the stress on patient safety. These factors have driven the demand to include simulation-based training in the core curricula for teaching the residents and undergraduate students.4 Simulation has been already incorporated in the core curriculum in many centers.5,6 Simulation offers standardized experience for the trainees and has been shown to improve not only technical skills but also nontechnical skills such as “leadership, team work, communication, situation awareness, decision-making, and awareness of personal limitations.”7 In orthopedics, simulation involves the use of cadavers, animals, synthetic bones, plastic models, box trainers, software tools, and computerized simulators.8 Simulation has been used in orthopedic training,9 operative planning,10 assisting diagnosis,1 actual surgery,11 and rehabilitation of the patients.12 Table 1 lists the various examples of simulation use in orthopedics. The traditional apprenticeship training model is serendipitous at best and results in an unequal training exposure to different trainee groups. Simulation can help avoid this by making practical “hands-on” training standardized, uniform, and comprehensive for all trainees.



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The modern era of arthroscopy originated in Japan. Professor Kenji Takagi developed an arthroscope in 1931, and Masaki Watanabe is credited with the development of first fiber-optic arthroscope in 1967.23 Although it took some decades to convince the orthopedic community of its utility, eventually it has become a popular diagnostic and therapeutic technique.

Arthroscopy presents novel and sometimes difficult learning challenges because it uses a completely different skill set compared with open orthopedic surgery, involving as it does the introduction of an arthroscope and instruments into the joint space through different entry points and using them to work in a specific area within the joint by the process of triangulation. The arthroscopy technique requires the surgeons to have technical dexterity and hand-eye coordination. The movement of the scope and the instruments is by pivoting around the entry points. To increase the area under view with minimum amount of arthroscope motion, various degrees of camera offset are used. This means that the center of view is not in the direction of movement of the scope and frequently causes difficulty for novice surgeons. Karahan et al24 identified basic motor skills required for arthroscopy to be “triangulation, depth perception, response orientation, reaction time and grip strength” and opined that basic motor training is beneficial for gaining arthroscopy skill. In one online survey, identification of anatomy and navigational skills were said to be the most important skills required in arthroscopy.25 Further difficulties may occur because of factors such as “the narrow field of vision, the lack of tactile feedback, and the need for interpretation of a three-dimensional surgical environment shown on a two-dimensional display.”26 Furthermore, arthroscopy training is time consuming and expensive.27 A study has shown that orthopedic residents feel less prepared to perform arthroscopic procedures compared with open procedures.28 Simulation has been seen as an excellent way to teach the skills required in arthroscopy, and therefore, this is one area in orthopedics where the use of simulation has generated maximum interest.

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The simulators used for arthroscopy training can be broadly classified into physical simulators, virtual-reality (VR) simulators, and hybrid simulators. The physical simulators include cadavers, live animals, plastic/rubber/latex models, and box trainers. The VR simulators can be further subclassified as video based (VB) and computer based. Hybrid simulators are those that combine VR simulation with physical components that allow real tactile feedback instead of through a haptic feedback device.

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Cadavers are the most realistic mode of simulation for arthroscopic training. Both fresh frozen and embalmed cadavers have been used in minimally invasive surgery (MIS) training. For arthroscopy training, cadaver joints should be flexible. Soft-embalming techniques such as Thiel29 and phenol-embalming techniques maintain tissue properties and preserve joint movements and are optimal for arthroscopy training. Safir et al25 in their study found cadavers to be the most favored simulation model for learning arthroscopy skills among orthopedic surgeons. Grechenig et al30 described an arthroscopic training model using cadaver joints. Cadaver joints with varied degree of dissection were used after a special embalming technique. The authors maintained that practice on artificial joints and cadavers can be used to master the arthroscopy technique. However, there are several disadvantages with the use of cadavers for training. It is expensive, does not provide feedback, and is not readily available. The haptic properties of cadavers may differ from that of living tissue.31 There is also an inherent risk of transmission of infectious disease with the use of cadavers.32 Cadaveric joints may not include the types of acute pathology that is most useful for operative teaching. Normally, cadavers cannot be reused, but Blaschko et al33 described a technique of coordinated and multiple use of cadavers to increase the availability of cadavers in surgical training. The authors stated that with adequate time in between the first use and the subsequent use, the tissue properties could be maintained with proper refrigeration.

A study found the transfer of surgical skills acquired through practice on cadavers to a human model.34 Most of the arthroscopic residency and fellowship programs in the United States have cadaver laboratories.35 Many arthroscopic workshops in the past have used cadavers as means of training. Some authors opine that workshops or short skill training courses cannot replace hands-on experience.36 Furthermore, a systematic review showed lack of evidence for the transferability of skills to the operation theater acquired during cadaveric workshops.37 Nevertheless, these short training courses provide a platform for novice surgeons to learn new skills and for experts to refresh the skills.38

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Bovine knee,39,40 porcine knee,41 and porcine shoulder42 have been used to learn arthroscopy. One study found anaesthetized animals to be better than cadavers for training in vascular complications such as bleeding.43 Although the realism is more than in plastic models and box trainers, animals are similar to cadavers in that they are expensive, they are not reusable, and there is lack of feedback. Some countries have banned their use for training purposes.44 Maintaining an animal laboratory is expensive and requires “licensed animal caretakers, housing, veterinary care, anaesthesia, and the disposal of hazardous wastes.”45 Furthermore, religious sentiments need to be considered before their use.46

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Box Trainers

Box trainers are a simple and cost-effective alternative to expensive VR simulators (discussed later) for learning basic skills such as visualization and triangulation. The use of box trainers for increasing performance in laparoscopy is well-known.47–50 One study showed that after practicing basic visuomotor tasks on a laparoscopic simulator, the arthroscopy performance of the trainees on a plastic knee model improved significantly.51 There is contrasting evidence in literature regarding the efficacy of box trainers compared with VR simulators. Some studies comparing box trainers and VR trainers have found both to be equally effective for acquisition of laparoscopic skills by novice learners,50,52 although a recent randomized control trial (RCT) comparing the effectiveness of box trainers, VR simulator, and mental training for basic laparoscopic skills found VR simulator training to be the most optimal method.53 The disadvantages of box trainers are the lack of realism and the need for supervision and guidance.

As the hand-eye coordination and psychomotor skills that are required for arthroscopy are similar to those for laparoscopy, it is reasonable to assume that box trainers can also be used to improve arthroscopic skills, although evidence for this is lacking. However, Howells et al54 noted several differences between skills required for laparoscopy and arthroscopy. According to them, in arthroscopy, “one hand is often used for camera manipulation, the instruments are shorter than for laparoscopy, the operating field is a more confined space, and there is a greater degree of tactile feedback from the cartilaginous surfaces.”54 In our literature search, we found only 2 references for box trainers that have been developed specifically for arthroscopy. Patil et al55 described a simple inexpensive box trainer made from a cardboard box and webcam attached at an angle of 30 degrees to an embolectomy catheter to simulate a knee model for practicing triangulation and hand-eye coordination skills. Meyer et al56 described a system incorporating arthroscopic instruments and a “black box” to master the basic arthroscopic skills. However, a distinct disadvantage of these box trainers is their inability to manipulate the limb, which is an essential part of the arthroscopy procedure.

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Plastic/Rubber/Latex Models

The ALEX shoulder arthroscopy model (Sawbones, Linvatec Corporation) has been used commonly for learning basic shoulder arthroscopy skills and has been found beneficial.57,58 Hillway knee and shoulder models59 are other examples of the plastic models used. The advantages of these models are portability and cost-effectiveness because of the possibility of repeated use. Grober et al32 found low-fidelity bench top models to be equally effective compared with live animal training for acquisition of surgical skills. A recent study to ascertain the effectiveness of these models found them to be useful in training novice surgeons before arthroscopy on cadavers.60

The lack of realism or low fidelity is the chief drawback of plastic models.61,62 Their role in training for orthopedic MIS is hampered by their limited ability to model physiologic process or anatomic variability. Another problem with plastic models is the need for continuous repair and maintenance.

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Virtual-Reality Simulators

The term virtual reality refers to the computer-generated environment with which the user can interact with the help of visual, audio, and haptic feedback as if he or she is a part of that imaginary environment.1 The chief working components of VR environment include immersion, that is, the user should feel as if he or she is actually present (immersed) in that environment; navigation, that is, the user is able to move through the virtual space; and interaction, that is, the user is able to interact with the objects in the virtual environment and is able to inflict changes.63 Mohan and Proctor1 referred to it as the Play Station for future surgeons. The list of specialties/procedures in medical science using VR simulation is long and includes angiography, bronchoscopy, gastrointestinal endoscopy, laparoscopy, otolaryngology, urology, and gynaecology.6,7 Virtual-reality simulation has the advantage that it is realistic, repeatable, and not associated with ethical issues. The disadvantage is the cost and lack of widespread availability. Virtual-reality simulators are especially useful in surgery. They provide an opportunity for self-directed learning and feedback in line with the adult-learning principles. With the feedback provided at the end of the procedure, the trainee can take important cues and refine his or her skill further. These simulators can be adjusted to the individual’s learning needs. Training of surgical residents in the traditional apprenticeship model is expensive,4 and VR simulation may prove to be more cost-effective in the long run. However, the evidence for this is lacking. As Mantovani et al64 stated, “virtual reality can provide a medium to learn by doing, through first-person experience.” This is in sharp contrast to traditional “see one, do one, teach one” approach. In a study to determine the usefulness of surgical simulators to teach shoulder anatomy, Hariri et al65 found it to be as effective as traditional textbook teaching. Knobe et al66 found simulator-based anatomy teaching more effective than the traditional dissection alone. The implementation of VR in resident training increases operating room throughput by reducing operative times and producing higher-quality outcomes.67

The orthopedic community has not embraced VR fully,4 and some remain skeptical.68 Probably, this is the reason why arthroscopy lags behind its counterpart laparoscopy, where simulation has been used for quite some time now.4

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Video-Based VR Simulators

Purely VB arthroscopy simulators have also been described in the literature. These VB simulators may aid in improving cognitive skills but lack psychomotor skills training. The VB simulator described by Cooper et al69 stored actual surgery videos and displayed the images in response to the position of arthroscopy instruments. The disadvantages as noted by Ward et al70 were the lack of haptic feedback and inability to incorporate tissue deformation.

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Computer-Based VR Simulators

Computer-based VR simulators for arthroscopy should ideally incorporate a haptic feedback, realistic tissue deformation, and a manipulable limb. Haptics refers to the modality of touch and associated sensory feedback.71 In simpler words, it means the sense of tissue touch/resistance. It is a bidirectional process, whereby in response to an input (force) applied through operators’ action, the computer sends an output (resistance, vibration, etc) through a mechanical device that uses motors, back to the operators’ hand or end effector, that is, the tool. In a virtual world, if one is able to move through a solid surface, the realism is lost. This feeling of resistance while navigating through various joint structures is essential for optimal simulation of arthroscopy. The haptic feedback in a VR arthroscopy simulator can be active as provided by a mechanical haptic device (eg, (PHANTOM OMNI by Sensable Technologies72) or passive owing to intrinsic property of the instrument. Furthermore, usually this feedback is provided at the tip of the tool by an interaction with the virtual environment rather than along the length of the tool. Zivanovic et al44 described “Orthoforce,” a haptic device that provided feedback through the length of the virtual instrument. Tenzer et al73 refined it further by adding vibration modality to this haptic device. The aim of simulation training as some authors put it is, “to imitate reality, or rather, to mimic reality to the closest extent possible so that the learner is in a state of ‘suspended disbelief’ and he believes himself to be undergoing a real experience.”74 On the other hand, too much of force feedback will hamper the instrument movements through the joint model. The optimal amount of haptic feedback required to be incorporated in VR simulators for core arthroscopy training has not been quantified.8

Tissue deformation should be realistic when manipulated in a VR simulator. Obtaining optimal deformation has been the most challenging factor in simulator design as it requires high computational power. The complex properties of soft tissue and their interactions with instruments in the virtual world are difficult to reproduce. As Otaduy et al75 stated, “Contact, with its associated problems of collision detection, collision response, and friction handling, is often a computational bottleneck.” Several techniques to model tissue deformation have been used, which include finite-element methods, mass-spring models, boundary element methods, and so on. However, none has been found to be better than the rest, with regard to optimal soft tissue deformation.76

Manipulation and positioning of the limb to visualize different joint structures is an essential component of knee arthroscopy. For ease of access during knee arthroscopy, varus-valgus stress in various degrees of knee flexion is required. Similarly, during shoulder arthroscopy, manipulation of the limb is required to visualize the entire shoulder joint. The addition of a manipulable limb to a VR simulator increases realism.

The work on arthroscopy VR simulators began in the mid-90s. The initial simulators described had either limited or no haptic feedback. These included simulators described by Ziegler et al77 and the Sheffield Knee Arthroscopy Training System.61 Moreover, these simulators lacked tissue deformation.

Haptic feedback with tissue deformation was incorporated in simulators described by Gibson et al78 and Heng et al,79 knee arthroscopy surgical trainer by Mabrey et al,80 the Virtual Environment Knee Arthroscopy Training System by Logan et al,81 and GeRTiSS [Generic Real Time Surgery Simulation] by Alcaniz et al.82 Hurmusiadis et al83 described the development of a pure software-based arthroscopy simulation program to teach the cognitive aspects of arthroscopy using virtual instruments. This software is accessible over the Internet. Advantages of this system as stated by the authors are as follows: it can be accessed from anywhere through the Internet, no special equipment is required, real-time interaction between the user and the system is possible, and it provides automated feedback on performance.83 Recently, Rasool and Sourin84 described an approach of using merged real arthroscopic images augmented with 3-dimensional object models to increase realism during arthroscopic VR simulator experience.

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The Hybrid VR Simulators

These VR simulators incorporate the natural tactile feedback provided by the physical components of a limb replica or model instead of a force-feedback mechanical device. This tactile feedback is also known as passive haptics.85 They include the refined version of Sheffield Knee Arthroscopy Training System85 and PASSPORT86 [Practice Arthroscopic Surgical Skills for Perfect Operative Real-life Treatment]. Both use a combined virtual-physical model where the physical components provide the tactile feedback.

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Commercially Available Arthroscopy VR Simulators

At present, we could find only 3 commercially available high-fidelity VR arthroscopy simulators. They include VirtaMed ArthroS,87 ARTHRO Mentor,88 ArthroSim.89 The details are given in Table 2.



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Most of the studies on simulation have highlighted the advantages of simulator-based training to develop psychomotor skills for aspiring surgeons. Several studies have found VR simulators to have good construct validity, that is, the ability to differentiate between novice and expert surgeons.27,86,90,91,93,94 Furthermore, the literature suggests the greatest performance gain for novice- or junior-level trainees.92,93 Andersen et al92 in an RCT found that inexperienced subjects even outperformed the experienced subjects after completion of scheduled 5-hour training on a VR simulator. Transfer of these learned skills to the operation theater during real-time surgery is of paramount importance. This transfer validity of VR simulators in arthroscopy has been scarcely studied.95,96 One RCT compared 2 groups of orthopedic trainees with minimal arthroscopy experience. The study group received training on a knee bench-top model for a total of 18 simulated arthroscopies, whereas the control group received the traditional operation theater training. At the end of the training session, trainees were assessed during real-time arthroscopy in an operation theater using the arthroscopy procedure-based assessment of Orthopaedic Competence Assessment Project97 and a global rating scale. The results showed significantly better performance by the simulator-trained group.98

Retention of skills after simulation training has been studied by a number of authors. Howells et al99 reported loss of initial improvement at repeat testing for arthroscopic Bankart suture after 6 months. The authors stated the need for regular practice to maintain proficiency level in skills learnt. Similarly, another study retesting the novices after initial training on a laparoscopic simulator found deterioration of initial performance at periods of 6 to 18 months.100 However, in a longitudinal study, Gomoll et al94 found significant improvement in the trainee performance in shoulder arthroscopy on retesting 3 years after simulator training. Similarly, Jackson et al101 found no loss of skill in residents for arthroscopic meniscal repair even after a break of 6 months as assessed by motion analysis. Furthermore, practice has been found to improve self-assessment during simulator training.102

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Other Factors Affecting Skill Acquisition

It has been argued that factors other than the quantum of practice can affect skill acquisition. Alvand et al26 suggested in a study that significant variations in the arthroscopic ability among the medical students may be due to variations in innate skills rather than the training provided. This variation in innate skills for psychomotor tasks has implications for the need to objectively assess the students or trainees before enrolling them for MIS courses.103,104 This has been echoed by Bayona et al105 who stated that “competence should be objectively evaluated before the surgeon performs his or her first intervention.” One the other hand, it has also been suggested that self-reported interest in surgery is a better predictor than innate skills for learning curve in simulated MIS tasks.106 Some authors stated that the increased computer video game experience correlates with VR simulator performance.107,108 However, many recent studies have contradicted this hypothesis.109–111

Surprisingly, sex differences have also been found to exist with respect to simulation, with men showing higher interest112 and also having a better performance as compared with their women counterparts on laparoscopic trainers.111,113,114 It has been suggested that these differences should be taken into account while planning and organizing training and assessment using simulator.112 However, Gomoll et al90 found no sex differences in performance on arthroscopy VR simulator.

Timing of simulator practice was not found to affect improvement in subjects’ skills,115 although practice duration of less than 4 hours per day has been shown to avoid student fatigue and poor performance.36 Furthermore, it has been suggested that training on interval basis is more fruitful than extensive practice of short duration.116 Simulation training can therefore be offered outside regular working hours with acceptable effectiveness.115

Many authors agree regarding the positive impact of instructor feedback on learning technical skills during simulation scenario.26,117,118 Strandbygaard et al118 in an RCT found decreased task completion time, repetitions, and increased self-perception about surgical skills in trainees who got instructor feedback compared with the control group without any feedback. Studying the impact of instruction method on trainees’ acquisition of MIS basic skills, Paige et al119 found the video- and text-based instructions to be useful and cost-effective than the faculty tutoring. Pernar et al120 found senior residents to be as effective as faculty in giving the basic surgical skill instruction to novices in a simulator center.

The positive effect of “preoperative warm-up” virtual laparoscopy exercises on surgical skills has been studied.121–124 Kahol et al121 found that preoperative warm-up exercises for 15 to 20 minutes improve surgical skill proficiency for the subsequent tasks. However, in a recent study, Weston et al125 in an RCT did not find any benefit of warm-up exercises in the performance of laparoscopic cholecystectomy or appendicectomy.

In a study to determine the effect of soft skills on VR simulator performance, Maschuw et al126 found that negative stress coping and lack of self-efficacy were related with poor VR performance of novices. Another study found that alcohol intake and sleep deprivation before a surgical task correlated with decreased surgical dexterity the following morning.127

Economy of movement characterizes operations performed by an experienced surgeon. Experienced surgeons achieve their tasks with precision and economy of motion, which can be assessed by VR simulator. The expert surgeons use less force for manipulation during arthroscopy compared with their novice counterparts. Virtual-reality simulators have inbuilt system to record the kinematic data and provide output in the form of metrics. These data include task completion time, instrument speed, path length, number of collisions, forces applied, and so on. Thus, they provide a quantitative assessment. Virtual reality can also provide opportunity to assess multiple users at the same time.128

The variety of arthroscopic trainers available can cause difficulty for surgical trainers to choose the appropriate trainer for their needs. We suggest a 3-step approach for arthroscopic simulator training (Table 3). The first step would be to provide hand-eye coordination and simple manipulation training; box trainers are the cheap and ideal way to do this. The second step would be to provide instrument navigation skills and recognition of joint anatomy, best done by using cadavers/animals or the basic training modules in VR simulators. The third step would be to provide surgical skills to deal with joint pathology; this could be done by using cadavers (for some degenerative pathology) and VR simulators for the rest. We feel that a hybrid approach wherein different simulators are used in combination is the best way to cancel out the drawbacks of each, while providing value addition for skill acquisition (eg, combining a cadaver session with a VR simulator). One must remember, however, that simulation only shifts some of the learning from the operating room to the skills laboratory and that the final teacher must remain, as always, to be the actual patient.



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Simulation is now well entrenched in medical education and training but has not found universal acceptance in all fields as yet. Arthroscopy, for example, has lagged behind its sister disciplines in the use of this training modality. However, as this review shows, the situation is now rapidly changing, and simulation is increasingly being used in arthroscopic training for the acquisition of both basic and advanced skills. It is to be hoped that this will shorten learning times and reduce surgical errors in the training period. A number of such simulators are commercially available, but further studies are needed to establish predictive and transfer validity of these simulators. Equivalence of simulator training with real surgical experience is also yet to be established. Simulation has also been used for the assessment of arthroscopic skills using both technical and traditional objective assessment tools. The consensus at present seems to be that simulators are useful in arthroscopic training but are adjuncts to real experience and cannot wholly replace it. The available VR simulators at present are largely limited to the knee and shoulder joints. With the development of more sophisticated and universal simulators in this field and with the emergence of more scientific data, it is likely that simulators will carve out an important niche for themselves in arthroscopic training of the future.

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1. Mohan A, Proctor M. Virtual reality—a `play station’ of the future. A review of virtual reality and orthopaedics. Acta Orthop Belg 2006; 72 (6): 659–663.
2. Ziv A, Small SD, Wolpe PR. Patient safety and simulation-based medical education. Med Teach 2000; 22 (5): 489–496.
3. Coles TR, Meglan D, John NW. The role of haptics in medical training simulators: a survey of the state of the art. IEEE Trans Haptics 2011; 4 (1): 51–66.
4. Mabrey JD, Reinig KD, Cannon WD. Virtual reality in orthopaedics: is it a reality? Clin Orthop Relat Res 2010; 468 (10): 2586–2591.
5. Valentine RJ, Rege RV. Integrating technical competency into the surgical curriculum: doing more with less. Surg Clin N Am 2004; 84 (6): 1647–1667.
6. Lane J L, Slavin S, Ziv A. Simulation in medical education: a review. Simul Gaming 2001; 32 (3): 297–314.
7. Akaike M, Fukutomi M, Nagamune M, et al. Simulation-based medical education in clinical skills laboratory. J Med Invest 2012; 59 (1–2): 28–35.
8. Atesok K, Mabrey JD, Jazrawi LM, Egol KA. Surgical simulation in orthopaedic skills training. J Am Acad Orthop Surg 2012; 20 (7): 410–422.
9. Karam MD, Pedowitz RA, Natividad H, Murray J, Marsh JL. Current and future use of surgical skills training laboratories in orthopaedic resident education: a national survey. J Bone Joint Surg Am 2013; 95 (1): e4.
10. Seel JM, Mahmoud AH, Eckman K, Jaramaz B, Davidson D, DiGioia AM 3rd. Three-dimensional planning and virtual radiographs in revision total hip arthroplasty for instability. Clin Orthop Relat Res 2006; 442: 35–38.
11. Hinsche AF, Smith R. Image-guided surgery. Curr Orthop 2001; 15 (4): 296–303.
12. Burdea G, Popescu V, Hentz V, Colbert K. Virtual reality based orthopaedic telerehabilitation. IEEE Trans Rehabil Eng 2000; 8 (3): 430–432.
13. Handels H, Ehrhardt J, Plotz W, Poppl SJ. Three-dimensional planning and simulation of hip operations and computer-assisted construction of endoprostheses in bone tumor surgery. Comput Aided Surg 2001; 6 (2): 65–76.
    14. Sourina O, Sourin A, Sen HT. Virtual orthopedic surgery training on personal computer. Int J Inform Technol 2000; 6 (1): 16–29.
      15. Vankipuram M, Kahol K, McLaren A, Panchanathan S. A virtual reality simulator for orthopedic basic skills: a design and validation study. J Biomed Inform 2010; 43 (5): 661–668.
        16. Reinig K, Lee C, Rubinstein D, Bagur M, Spitzer V. The United States military’s thigh trauma simulator. Clin Orthop Relat Res 2006; 442: 45–56.
          17. Blyth P, Stott NS, Anderson IA. Virtual reality assessment of technical skill using the Bonedoc DHS simulator. Injury 2008; 39 (10): 1127–1133.
            18. Tonetti J, Vadcard L, Girard P, Dubois M, Merloz P, Troccaz J. Assessment of a percutaneous iliosacral screw insertion simulator. Orthop Traumatol Surg Res 2009; 95 (7): 471–477.
              19. Malek S, Phillips R, Mohsen A, Viant W, Bielby M, Sherman K. Computer assisted orthopaedic surgical system for insertion of distal locking screws in intra-medullary nails: a valid and reliable navigation system. Int J Med Robot 2005; 1 (4): 34–44.
                20. Joskowicz L, Milgrom C, Simkin A, Tockus L, Yaniv Z. FRACAS: a system for computer-aided image-guided long bone fracture surgery. Comput Aided Surg 1998; 3 (6): 271–288.
                  21. Riener R, Frey M, Proll T, Regenfelder F, Burgkart R. Phantom-based multimodal interactions for medical education and training: the Munich Knee Joint Simulator. IEEE Trans Inf Technol Biomed 2004; 8 (2): 208–216.
                    22. Tillett ED, Rogers R, Nyland J. A reusable suture anchor for arthroscopy psychomotor skills training. Arthroscopy 2003; 19 (3): E20.
                      23. The Impact of The Arthroscopy Association of North America on the Development of Arthroscopic Surgery. Available at: Accessed February 11, 2013.
                      24. Karahan M, Unalan PC, Bozkurt S, et al. Correlation of basic motor skills with arthroscopic experience [in Turkish]. Acta Orthop Traumatol Turc 2009; 43 (1): 49–53.
                      25. Safir O, Dubrowski A, Mirsky L, Lin C, Backstein D, Carnahan A. What skills should simulation training in arthroscopy teach residents? Int J Comput Assist Radiol Surg 2008; 3 (5): 1–5.
                      26. Alvand A, Auplish S, Gill H, Rees J. Innate arthroscopic skills in medical students and variation in learning curves. J Bone Joint Surg Am 2011; 93 (19): e115(1–9).
                      27. Pedowitz RA, Esch J, Snyder S. Evaluation of a virtual reality simulator for arthroscopy skills development. Arthroscopy 2002; 18 (6): E29.
                      28. Hall MP, Kaplan KM, Gorczynski CT, Zuckerman JD, Rosen JE. Assessment of arthroscopic training in U.S. orthopedic surgery residency programs—a resident self-assessment. Bull NYU Hosp Jt Dis 2010; 68 (1): 5–10.
                      29. Thiel W. The preservation of the whole corpse with natural color [in German]. Ann Anat 1992; 174 (3): 185–195.
                      30. Grechenig W, Fellinger M, Fankhauser F, Weiglein AH. The Graz learning and training model for arthroscopic surgery. Surg Radiol Anat 1999; 21 (5): 347–350.
                      31. Higgins GA, Merrill GL, Hettinger LJ, Kaufmann CR, Champion HR, Satava RM. New simulation technologies for surgical training and certification: current status and future projections. Presence 1997; 6 (2): 160–172.
                      32. Grober ED, Hamstra SJ, Wanzel KR, et al. The educational impact of bench model fidelity on the acquisition of technical skill: the use of clinically relevant outcome measures. Ann Surg 2004; 240 (2): 374–381.
                      33. Blaschko SD, Brooks HM, Dhuy SM, Charest-Shell C, Clayman RV, McDougall EM. Coordinated multiple cadaver use for minimally invasive surgical training. JSLS 2007; 11 (4): 403–407.
                      34. Anastakis DJ, Regehr G, Reznick RK, et al. Assessment of technical skills transfer from the bench training model to the human model. Am J Surg 1999; 177 (2): 167–170.
                      35. Insel A, Carofino B, Leger R, Arciero R, Mazzocca AD. The development of an objective model to assess arthroscopic performance. J Bone Joint Surg Am 2009; 91 (9): 2287–2295.
                      36. Wanzel KR, Ward M, Reznick RK. Teaching the surgical craft: from selection to certification. Curr Probl Surg 2002; 39 (6): 573–659.
                      37. Gilbody J, Prasthofer AW, Ho K, Costa ML. The use and effectiveness of cadaveric workshops in higher surgical training: a systematic review. Ann R Coll Surg Engl 2011; 93 (5): 347–352.
                      38. Grange S. A virtual university infrastructure for orthopaedic surgical training with integrated simulation. University of Southampton website. Accessed January 21, 2013.
                      39. Unalan PC, Akan K, Orhun H, et al. A basic arthroscopy course based on motor skill training. Knee Surg Sports Traumatol Arthrosc 2010; 18 (10): 1395–1399.
                      40. Patel D, Gruhl JF. The use of bovine knees in operative arthroscopy. Orthopaedics 1983; 6: 1119.
                      41. Voto SJ, Clark RN, Zuelzer WA. Arthroscopic training using pig knee joints. Clin Orthop 1988; 226: 134–137.
                      42. Spławski R. Animal model of humeral joint for shoulder arthroscopy training [in Polish]. Chir Narzadow Ruchu Ortop Pol 2011; 76 (6): 324–326.
                      43. Giger U, Fresard I, Hafliger A, Bergmann M, Krahenbuhl L. Laparoscopic training on Thiel human cadavers: a model to teach advanced laparoscopic procedures. Surg Endosc 2008; 22 (4): 901–906.
                      44. Zivanovic A, Dibble E, Davies B. A high force haptic system for knee arthroscopy training. Int J HR 2006; 3 (4): 429–437.
                      45. Balcombe J. Medical training using simulation: toward fewer animals and safer patients. Altern Lab Anim 2004; 1: 553–560.
                      46. Goyal D, Goyal A, Brittberg M. Consideration of religious sentiments while selecting a biological product for knee arthroscopy. Knee Surg Sports Traumatol Arthrosc 2012; 21 (7): 1577–1586.
                      47. Clevin L, Grantcharov TP. Does box model training improve surgical dexterity and economy of movement during virtual reality laparoscopy? A randomised trial. Acta Obstet Gynecol Scand 2008; 87 (1): 99–103.
                      48. Tanoue K, Ieiri S, Konishi K, et al. Effectiveness of endoscopic surgery training for medical students using a virtual reality simulator versus a box trainer: a randomized controlled trial. Surg Endosc 2008; 22 (4): 985–990.
                      49. Madan AK, Frantzides CT. Substituting virtual reality trainers for inanimate box trainers does not decrease laparoscopic skills acquisition. JSLS 2007; 11 (1): 87–89.
                      50. Diesen DL, Erhunmwunsee L, Bennett KM, et al. Effectiveness of laparoscopic computer simulator versus usage of box trainer for endoscopic surgery training of novices. J Surg Educ 2011; 68 (4): 282–289.
                      51. Safir O, Dubrowski A, Williams C, Hui Y, Backstein D, Carnahan H. The benefits of Fundamentals of Laparoscopic Surgery (FLS) training on simulated arthroscopy performance. Stud Health Technol Inform 2012; 173: 412–417.
                      52. Vitish-Sharma P, Knowles J, Patel B. Acquisition of fundamental laparoscopic skills: is a box really as good as a virtual reality trainer? Int J Surg 2011; 9 (8): 659–661.
                      53. Mulla M, Sharma D, Moghul M, et al. Learning basic laparoscopic skills: a randomized controlled study comparing box trainer, virtual reality simulator, and mental training. J Surg Educ 2012; 69 (2): 190–195.
                      54. Howells NR, Brinsden MD, Gill HS, Carr AJ, Rees JL. Motion analysis: a validated method for showing skill levels in arthroscopy. Arthroscopy 2008; 24: 335–342.
                      55. Patil V, Odak S, Chian V, Chougle A. Use of webcam as arthroscopic training model for junior surgical trainees. Ann R Coll Surg Engl 2009; 91 (2): 161–162.
                      56. Meyer RD, Tamarapalli JR, Lemons JE. Arthroscopy training using a “black box” technique. Arthroscopy 1993; 9 (3): 338–340.
                      57. Martin KD, Belmont PJ, Schoenfeld AJ, Todd M, Cameron KL, Owens BD. Arthroscopic basic task performance in shoulder simulator model correlates with similar task performance in cadavers. J Bone Joint Surg Am 2011; 93 (21): e1271–e1275.
                      58. Ceponis PJ, Chan D, Boorman RS, Hutchison C, Mohtadi NG. A randomized pilot validation of educational measures in teaching shoulder arthroscopy to surgical residents. Can J Surg 2007; 50 (5): 387–393.
                      59. Hillway Surgical Ltd. Advanced models for simulated surgery. Chichester, UK. Available at Accessed January 3, 2013.
                      60. Butler A, Olson T, Koehler R, Nicandri G. Do the skills acquired by novice surgeons using anatomic dry models transfer effectively to the task of diagnostic knee arthroscopy performed on cadaveric specimens? J Bone Joint Surg Am 2013; 95 (3): e151–e158.
                      61. McCarthy AD, Hollands RJ. A commercially viable virtual reality knee arthroscopy training system. Stud Health Technol Inform 1998; 50: 302–308.
                      62. Sidhu RS, Park J, Brydges R, MacRae HM, Dubrowski A. Laboratory-based vascular anastomosis training: a randomized controlled trial evaluating the effects of bench model fidelity and level of training on skill acquisition. J Vasc Surg 2007; 45 (2): 343–349.
                      63. Marescaux J, Clément JM, Tassetti V, et al. Virtual reality applied to hepatic surgery simulation: the next revolution. Ann Surg 1998; 228 (5): 627–634.
                      64. Mantovani F, Castelnuovo G, Gaggioli A, Riva G. Virtual reality training for health-care professionals. Cyberpsychol Behav 2003; 6 (4): 389–395.
                      65. Hariri S, Rawn C, Srivastava S, Youngblood P, Ladd A. Evaluation of a surgical simulator for learning clinical anatomy. Med Educ 2004; 38 (8): 896–902.
                      66. Knobe M, Carow JB, Ruesseler M, et al. Arthroscopy or ultrasound in undergraduate anatomy education: a randomized cross-over controlled trial. BMC Med Educ 2012; 12: 85.
                      67. Saleh KJ, Novicoff WM, Rion D, MacCracken LH, Siegrist R. Operating-room throughput: strategies for improvement. J Bone Joint Surg Am 2009; 91 (8): 2028–2039.
                      68. Blyth P, Anderson IA, Stott NS. Virtual reality simulators in orthopedic surgery: what do the surgeons think? J Surg Res 2006; 131 (1): 133–139;discussion 140–142.
                      69. Cooper J, Ford L, Watson G. Video worlds: a training potential for non-invasive surgery. Department of Computer Science, University of Exeter. Research report 336. 1995.
                      70. Ward JW, Wills DPM, Sherman KE, Mohsen AMMA. The development of an arthroscopic surgical simulator with haptic feedback. Future Gener Comput Syst 1998; 14 (3): 243–251.
                      71. Mclaughlin ML, Hespanha J, Sukhatme G, eds. Introduction to Haptics, Touch in Virtual Environments: Haptics and the Design of Interactive Systems. New Jersey: Prentice-Hall; 2002: 1–31.
                      72. PHANTOM OMNI, Geomagic, Sensable group. Wilmington, MA. Available at: Accessed January 12, 2013.
                      73. Tenzer Y, Davies B, Rodriguez y Baena F. Investigation into the effectiveness of vibrotactile feedback to improve the haptic realism of an arthroscopy training simulator. Stud Health Technol Inform 2008; 132: 517–522.
                      74. Pai DR, Singh S. Medical simulation: overview, and application to wound modelling and management. Indian J Plast Surg 2012; 45 (2): 209–214.
                      75. Otaduy MA, Garre C, Gascon J, Miguel E, Perez AG, Zurdo JS. Modeling and Simulation of a Human Shoulder for Interactive Medical Applications. Available at: Accessed January 16, 2013.
                      76. Meier U, Lopez O, Monserrat C, Juan MC, Alcaniz M. Real-time deformable models for surgery simulation: a survey. Comput Methods Programs Biomed 2005; 77 (3): 183–197.
                      77. Ziegler R, Fischer G, Muller W, Gobel M. Virtual reality arthroscopy training simulator. Comput Biol Med 1995; 25 (2): 193–203.
                      78. Gibson S, Samosky J, Mor A, et al. Simulating arthroscopic knee surgery using volumetric object representations, real-time volume rendering and haptic feedback. LNCS 1997; 1205: 369–378.
                      79. Heng PA, Cheng CY, Wong TT, et al. Virtual reality based system for training on knee arthroscopic surgery. Stud Health Technol Inform 2004; 98: 130–136.
                      80. Mabrey JD, Gillogly SD, Kasser JR, et al. Virtual reality simulation of arthroscopy of the knee. Arthroscopy 2002; 18 (6): E28.
                      81. Logan IP, Wills DPM, Avis NJ, Mohsen AMMA, Sherman KP. Virtual environment knee arthroscopy training system. Simulation 1996; 28 (4): 17–22.
                      82. Alcaniz M, Monserrat C, Meier U, Juan C, Grau V, Gil JA. GeRTiSS: Generic Real Time Surgery Simulator, Medicine Meets Virtual Reality 11. Westwood JW, Hoffman HM, Mogel GT, Phillips R, Robb RA, Stredney D, eds. Amsterdam, the Netherlands: IOS Press; 2003: 16–18.
                      83. Hurmusiadis V, Rhode K, Schaeffter T, Sherman K. Virtual arthroscopy trainer for minimally invasive surgery. Stud Health Technol Inform 2011; 163: 236–238.
                      84. Rasool S, Sourin A. Image-driven virtual simulation of arthroscopy. Vis Comput 2013; 29 (5): 333–344.
                      85. Moody L, Waterworth A, Arthur JG, McCarthy AD, Harley PJ, Smallwood RH. Beyond the visuals: tactile augmentation and sensory enhancement in an arthroscopy simulator. Virtual Real 2009; 13 (1): 59–68.
                      86. Tuijthof GJ, van Sterkenburg MN, Sierevelt IN, van Oldenrijk J, Van Dijk CN, Kerkhoffs GM. First validation of the PASSPORT training environment for arthroscopic skills. Knee Surg Sports Traumatol Arthrosc 2010; 18 (2): 218–224.
                      87. VirtaMed ArthroS, VirtaMed AG, Zurich, Switzerland. Available at: Accessed February11, 2013.
                      88. ARTHRO Mentor, Simbionix, Cleveland, Ohio USA. Available at: Accessed February 11, 2013.
                      89. ArthroSim, Touch of Life Technologies (ToLTech), Aurora, Colorado, USA. Available at: Accessed February 11, 2013.
                      90. Gomoll AH, O’Toole RV, Czarnecki J, Warner JJ. Surgical experience correlates with performance on a virtual reality simulator for shoulder arthroscopy. Am J Sports Med 2007; 35 (6): 883–888.
                      91. Srivastava S, Youngblood PL, Rawn C, Hariri S, Heinrichs WL, Ladd AL. Initial evaluation of a shoulder arthroscopy simulator: establishing construct validity. J Shoulder Elbow Surg 2004; 13 (2): 196–205.
                      92. Andersen C, Winding TN, Vesterby MS. Development of simulated arthroscopic skills. Acta Orthop 2011; 82 (1): 90–95.
                      93. McCarthy AD, Moody L, Waterworth AR, Bickerstaff DR. Passive haptics in a knee arthroscopy simulator: is it valid for core skills training? Clin Orthop Relat Res 2006; 442: 13–20.
                      94. Gomoll AH, Pappas G, Forsythe B, Warner JJ. Individual skill progression on a virtual reality simulator for shoulder arthroscopy: a 3-year follow-up study. Am J Sports Med 2008; 36 (6): 1139–1142.
                      95. Modi CS, Morris G, Mukherjee R. Computer-simulation training for knee and shoulder arthroscopic surgery. Arthroscopy 2010; 26 (6): 832–840.
                      96. Slade Shantz JA, Leiter JR, Gottschalk T, Macdonald PB. The internal validity of arthroscopic simulators and their effectiveness in arthroscopic education [published online ahead of print October 2, 2012]. Knee Surg Sports Traumatol Arthrosc. doi: 10.1007/s00167-012-2228-7.
                      97. Pitts D, Rowley DI, Sher JL. Assessment of performance in orthopaedic training. J Bone Joint Surg Br 2005; 87 (9): 1187–1191.
                      98. Howells NR, Gill HS, Carr AJ, Price AJ, Rees JL. Transferring simulated arthroscopic skills to the operating theatre: a randomised blinded study. J Bone Joint Surg Br 2008; 90 (4): 494–499.
                      99. Howells NR, Auplish S, Hand GC, Gill HS, Carr AJ, Rees JL. Retention of arthroscopic shoulder skills learned with use of a simulator. Demonstration of a learning curve and loss of performance level after a time delay. J Bone Joint Surg Am 2009; 91 (5): 1207–1213.
                      100. Maagaard M, Sorensen JL, Oestergaard J, et al. Retention of laparoscopic procedural skills acquired on a virtual-reality surgical trainer. Surg Endosc 2011; 25 (3): 722–727.
                      101. Jackson WF, Khan T, Alvand A, et al. Learning and retaining simulated arthroscopic meniscal repair skills. J Bone Joint Surg Am 2012; 94 (17): e132.
                      102. MacDonald J, Williams RG, Rogers DA. Self-assessment in simulation-based surgical skills training. Am J Surg 2003; 185 (4): 319–322.
                      103. Salgado J, Grantcharov TP, Papasavas PK, Gagne DJ, Caushaj PF. Technical skills assessment as part of the selection process for a fellowship in minimally invasive surgery. Surg Endosc 2009; 23 (3): 641–644.
                      104. Grantcharov TP, Funch-Jensen P. Can everyone achieve proficiency with the laparoscopic technique? Learning curve patterns in technical skills acquisition. Am J Surg 2009; 197 (4): 447–449.
                      105. Bayona S, Fernandez-Arroyo JM, Martin I, Bayona P. Assessment study of insightARTHRO VR arthroscopy virtual training simulator: face, content, and construct validities. J Robot Surg 2008; 2: 151–158.
                      106. Bann S, Darzi A. Selection of individuals for training in surgery. Am J Surg 2005; 190 (1): 98–102.
                      107. Grantcharov TP, Bardram L, Funch-Jensen P, Rosenberg J. Impact of hand dominance, gender, and experience with computer games on performance in virtual reality laparoscopy. Surg Endosc 2003; 17 (7): 1082–1085.
                      108. Rosenthal R, Geuss S, Dell-Kuster S, Schafer J, Hahnloser D, Demartines N. Video gaming in children improves performance on a virtual reality trainer but does not yet make a laparoscopic surgeon. Surg Innov 2011; 18 (2): 160–170.
                      109. Harper JD, Kaiser S, Ebrahimi K, et al. Prior video game exposure does not enhance robotic surgical performance. J Endourol 2007; 21: 1207–1210.
                      110. Rosser JC Jr, Lynch PJ, Cuddihy L, Gentile DA, Klonsky J, Merrell R. The impact of video games on training surgeons in the 21st century. Arch Surg 2007; 142: 181–186; discussion 186.
                      111. Thorson CM, Kelly JP, Forse RA, Turaga KK. Can we continue to ignore gender differences in performance on simulation trainers? J Laparoendosc Adv Surg Tech A 2011; 21 (4): 329–333.
                      112. Konge L, Ali A, Sorensen M, Bitsch M. Gender differences among medical students in the approach to simulation [in Danish]. Ugeskr Laeger 2011; 173 (49): 3170–3173.
                      113. Elneel FH, Carter F, Tang B, Cuschieri A. Extent of innate dexterity and ambidexterity across handedness and gender: implications for training in laparoscopic surgery. Surg Endosc 2008; 22 (1): 31–37.
                      114. Madan AK, Harper JL, Frantzides CT, Tichansky DS. Nonsurgical skills do not predict baseline scores in inanimate box or virtual-reality trainers. Surg Endosc 2008; 22: 1686–1689.
                      115. Bonrath EM, Fritz M, Mees ST, et al. Laparoscopic simulation training: does timing impact the quality of skills acquisition?. Surg Endosc 2013; 27 (3): 888–894.
                      116. Gallagher AG, Ritter EM, Champion H, et al. Virtual reality simulation for the operating room: proficiency-based training as a paradigm shift in surgical skills training. Ann Surg 2005; 241 (2): 364–372.
                      117. Doll BB, Jacobs WJ, Sanfey AG, Frank MJ. Instructional control of reinforcement learning: a behavioral and neurocomputational investigation. Brain Res 2009; 1299: 74–94.
                      118. Strandbygaard J, Bjerrum F, Maagaard M, Winkel P, Larsen CR. Instructor feedback versus no instructor feedback on performance in a laparoscopic virtual reality simulator: a randomized trial. Ann Surg 2013; 257 (5): 839–844.
                      119. Paige JT, Yang T, Suleman R, et al. Role of instruction method in novices’ acquisition of minimally invasive surgical basic skills. J Laparoendosc Adv Surg Tech A 2011; 21 (8): 711–715.
                      120. Pernar LI, Smink DS, Hicks G, Peyre SE. Residents can successfully teach basic surgical skills in the simulation center. J Surg Educ 2012; 69 (5): 617–622.
                      121. Kahol K, Satava RM, Ferrara J, Smith ML. Effect of short-term pretrial practice on surgical proficiency in simulated environments: a randomized trial of the “preoperative warm-up” effect. J Am Coll Surg 2009; 208 (2): 255–268.
                      122. Calatayud D, Arora S, Aggarwal R, et al. Warm-up in a virtual reality environment improves performance in the operating room. Ann Surg 2010; 251 (6): 1181–1185.
                      123. Moldovanu R, Tarcoveanu E, Dimofte G, Lupascu C, Bradea C. Preoperative warm-up using a virtual reality simulator. JSLS 2011; 15 (4): 533–538.
                      124. Willaert WI, Aggarwal R, Daruwalla F, et al. Simulated procedure rehearsal is more effective than a preoperative generic warm-up for endovascular procedures. Ann Surg 2012; 255 (6): 1184–1189.
                      125. Weston MK, Stephens JH, Schafer A, Hewett PJ. Warm-up before laparoscopic surgery is not essential [published online ahead of print November 22, 2012]. ANZ J Surg. doi: 10.1111/j.1445-2197.2012.06321.x.
                      126. Maschuw K, Schlosser K, Kupietz E, Slater EP, Weyers P, Hassan I. Do soft skills predict surgical performance?: a single-center randomized controlled trial evaluating predictors of skill acquisition in virtual reality laparoscopy. World J Surg 2011; 35 (3): 480–486.
                      127. Kocher H, Warwick J, Al-Ghnaniem R, Patel A. Surgical dexterity after a ‘night out on the town’. ANZ J Surg 2006; 76 (3): 110–112.
                      128. Machado LS, Moraes RM. Virtual reality and beyond: the LabTEVE at UFPB in Brazil. SBC J 3D Interact Sys 2011; 2 (2): 48–51.

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