Virtual Reality Simulation Training Research Articles

Learning Curves of Virtual Mastoidectomy in Distributed and Massed Practice.

Repeated and deliberate practice is crucial in surgical skills training, and virtual reality (VR) simulation can provide self-directed training of basic surgical skills to meet the individual needs of the trainee. Assessment of the learning curves of surgical procedures is pivotal in understanding skills acquisition and best-practice implementation and organization of training. To explore the learning curves of VR simulation training of mastoidectomy and the effects of different practice sequences with the aim of proposing the optimal organization of training. A prospective trial with a 2 × 2 design was conducted at an academic teaching hospital. Participants included 43 novice medical students. Of these, 21 students completed time-distributed practice from October 14 to November 29, 2013, and a separate group of 19 students completed massed practice on May 16, 17, or 18, 2014. Data analysis was performed from June 6, 2014, to March 3, 2015. Participants performed 12 repeated virtual mastoidectomies using a temporal bone surgical simulator in either a distributed (practice blocks spaced in time) or massed (all practice in 1 day) training program with randomization for simulator-integrated tutoring during the first 5 sessions. Performance was assessed using a modified Welling Scale for final product analysis by 2 blinded senior otologists. Compared with the 19 students in the massed practice group, the 21 students in the distributed practice group were older (mean age, 25.1 years), more often male (15 [62%]), and had slightly higher mean gaming frequency (2.3 on a 1-5 Likert scale). Learning curves were established and distributed practice was found to be superior to massed practice, reported as mean end score (95% CI) of 15.7 (14.4-17.0) in distributed practice vs. 13.0 (11.9-14.1) with massed practice (P = .002). Simulator-integrated tutoring accelerated the initial performance, with mean score for tutored sessions of 14.6 (13.9-15.2) vs. 13.4 (12.8-14.0) for corresponding nontutored sessions (P < .01) but at the cost of a drop in performance once tutoring ceased. The performance drop was less with distributed practice, suggesting a protective effect when acquired skills were consolidated over time. The mean performance of the nontutored participants in the distributed practice group plateaued on a score of 16.0 (15.3-16.7) at approximately the ninth repetition, but the individual learning curves were highly variable. Novices can acquire basic mastoidectomy competencies with self-directed VR simulation training. Training should be organized with distributed practice, and simulator-integrated tutoring can be useful to accelerate the initial learning curve. Practice should be deliberate and toward a standard set level of proficiency that remains to be defined rather than toward the mean learning curve plateau.

OP08.01: Randomised clinical trial of virtual reality simulation training for gynecological transvaginal ultrasound skills

OP08.01: Randomised clinical trial of virtual reality simulation training for gynecological transvaginal ultrasound skills

Laparoscopic skill improvement after virtual reality simulator training in medical students as assessed by augmented reality simulator.

Definitive assessment of laparoscopic skill improvement after virtual reality simulator training is best obtained during an actual operation. However, this is impossible in medical students. Therefore, we developed an alternative assessment technique using an augmented reality simulator. Nineteen medical students completed a 6-week training program using a virtual reality simulator (LapSim). The pretest and post-test were performed using an object-positioning module and cholecystectomy on an augmented reality simulator(ProMIS). The mean performance measures between pre- and post-training on the LapSim were compared with a paired t-test. In the object-positioning module, the execution time of the task (P < 0.001), left and right instrument path length (P = 0.001), and left and right instrument economy of movement (P < 0.001) were significantly shorter after than before the LapSim training. With respect to improvement in laparoscopic cholecystectomy using a gallbladder model, the execution time to identify, clip, and cut the cystic duct and cystic artery as well as the execution time to dissect the gallbladder away from the liver bed were both significantly shorter after than before the LapSim training (P = 0.01). Our training curriculum using a virtual reality simulator improved the operative skills of medical students as objectively evaluated by assessment using an augmented reality simulator instead of an actual operation. We hope that these findings help to establish an effective training program for medical students.

A new possibility in thoracoscopic virtual reality simulation training: development and testing of a novel virtual reality simulator for video-assisted thoracoscopic surgery lobectomy

The aims of this study were to develop virtual reality simulation software for video-assisted thoracic surgery (VATS) lobectomy, to explore the opinions of thoracic surgeons concerning the VATS lobectomy simulator and to test the validity of the simulator metrics. Experienced VATS surgeons worked with computer specialists to develop a VATS lobectomy software for a virtual reality simulator. Thoracic surgeons with different degrees of experience in VATS were enrolled at the 22nd meeting of the European Society of Thoracic Surgeons (ESTS) held in Copenhagen in June 2014. The surgeons were divided according to the number of performed VATS lobectomies: novices (0 VATS lobectomies), intermediates (1-49 VATS lobectomies) and experienced (>50 VATS lobectomies). The participants all performed a lobectomy of a right upper lobe on the simulator and answered a questionnaire regarding content validity. Metrics were compared between the three groups. We succeeded in developing the first version of a virtual reality VATS lobectomy simulator. A total of 103 thoracic surgeons completed the simulated lobectomy and were distributed as follows: novices n = 32, intermediates n = 45 and experienced n = 26. All groups rated the overall user realism of the VATS lobectomy scenario to a median of 5 on a scale 1-7, with 7 being the best score. The experienced surgeons found the graphics and movements realistic and rated the scenario high in terms of usefulness as a training tool for novice and intermediate experienced thoracic surgeons, but not very useful as a training tool for experienced surgeons. The metric scores were not statistically significant between groups. This is the first study to describe a commercially available virtual reality simulator for a VATS lobectomy. More than 100 thoracic surgeons found the simulator realistic, and hence it showed good content validity. However, none of the built-in simulator metrics could significantly distinguish between novice, intermediate experienced and experienced surgeons, and further development of the simulator software is necessary to develop valid metrics.

Simulator training for endobronchial ultrasound: a randomised controlled trial.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is very operator dependent and has a long learning curve. Simulation-based training might shorten the learning curve, and an assessment tool with solid validity evidence could ensure basic competency before unsupervised performance.A total of 16 respiratory physicians, without EBUS experience, were randomised to either virtual-reality simulator training or traditional apprenticeship training on patients, and then each physician performed EBUS-TBNA procedures on three patients. Three blinded, independent assessor assessed the video recordings of the procedures using a newly developed EBUS assessment tool (EBUSAT).The internal consistency was high (Cronbach's α=0.95); the generalisability coefficient was good (0.86), and the tool had discriminatory ability (p<0.001). Procedures performed by simulator-trained novices were rated higher than procedures performed by apprenticeship-trained novices: mean±sd are 24.2±7.9 points and 20.2±9.4 points, respectively; p=0.006. A pass/fail standard of 28.9 points was established using the contrasting groups method, resulting in 16 (67%) and 20 (83%) procedures performed by simulator-trained novices and apprenticeship-trained novices failing the test, respectively; p<0.001.The endobronchial ultrasound assessment tool could be used to provide reliable and valid assessment of competence in EBUS-TBNA, and act as an aid in certification. Virtual-reality simulator training was shown to be more effective than traditional apprenticeship training.

The Relationship of Endoscopic Proficiency to Educational Expense for Virtual Reality Simulator Training Amongst Surgical Trainees.

With the introduction of Fundamentals of Endoscopic Surgery, training methods in flexible endoscopy are being augmented with simulation-based curricula. The investment for virtual reality simulators warrants further research into its training advantage. Trainees were randomized into bedside or simulator training groups (BED vs SIM). SIM participated in a proficiency-based virtual reality curriculum. Trainees' endoscopic skills were rated using the Global Assessment of Gastrointestinal Endoscopic Skills (GAGES) in the patient care setting. The number of cases to reach 90 per cent of the maximum GAGES score and calculated costs of training were compared. Nineteen residents participated in the study. There was no difference in the average number of cases required to achieve 90 per cent of the maximum GAGES score for esophagogastroduodenoscopy, 13 (SIM) versus11 (BED) (P = 0.63), or colonoscopy 21 (SIM) versus 4 (BED) (P = 0.34). The average per case cost of training for esophagogastroduodenoscopy was $35.98 (SIM) versus $39.71 (BED) (P = 0.50), not including the depreciation costs associated with the simulator ($715.00 per resident over six years). Use of a simulator appeared to increase the cost of training without accelerating the learning curve or decreasing faculty time spent in instruction. The importance of simulation in endoscopy training will be predicated on more cost-effective simulators.

Testing basic competency in knee arthroscopy using a virtual reality simulator: exploring validity and reliability.

Diagnostic knee arthroscopy is a common procedure that orthopaedic residents are expected to learn early in their training. Arthroscopy requires a different skill set from traditional open surgery, and many orthopaedic residents feel less prepared for arthroscopic procedures. Virtual reality simulation training and testing provide an opportunity to ensure basic competency before proceeding to supervised procedures in patients. Twenty-six physicians (thirteen novices and thirteen experienced arthroscopic surgeons) were voluntarily recruited to perform a test consisting of five arthroscopic procedures on a knee arthroscopy simulator. Performance was evaluated by obtaining predefined metrics from the simulator for each procedure, and z-scores, describing suboptimal performance, were calculated from the metrics. The intercase reliability of the simulator metrics was explored by calculating an intraclass correlation coefficient. Finally, a pass-or-fail standard was set with use of the contrasting groups method, and the consequences of the pass-or-fail standard were explored. One procedure was excluded from the final test because of a lack of validity. The total Z-scores for the four procedures included in the final test showed an intercase reliability of 0.87 (95% confidence interval, 0.78 to 0.93). The total mean z-score (and standard deviation) was 38.6 ± 27.3 points for the novices and 0.0 ± 9.1 points for the experienced surgeons (p < 0.0005). The pass-or-fail standard was set at a total z-score of 15.5 points, resulting in two of the novices passing the test and a single experienced surgeon failing the test. By combining four procedures on a virtual reality arthroscopy simulator, it was possible to create a valid, reliable, and feasible test of basic arthroscopic competency and to establish a credible pass-or-fail standard. The simulation-based test and pass-or-fail standard could aid in assessing and ensuring basic competency of future orthopaedic residents before proceeding to supervised procedures in patients.

A new CPD website for ultrasound.

Ultrasound publishes articles on a wide range of subjects relevant to those involved in medical ultrasound, including clinical applications, new technologies, professional issues and education and training. Although many of these articles are research reports, most issues include at least one review article aimed at providing basic education in one of these subject areas. Ultrasound is intended as an educational resource for ultrasound users worldwide including BMUS members, but BMUS members can now get more benefit from studying our educational articles. Our publisher, SAGE Publications, has commissioned its website designer to create a new CPD website for use in conjunction with the journal. BMUS members will be able to access this new site via the members’ area of the BMUS website and register with their name and email address. The site will give access to a selection of educational articles, each accompanied by a set of questions provided by the authors. After studying an article, members can then answer the questions, and if they achieve the 70% pass mark, be awarded a CPD certificate. Each registered user will have an account that records all CPD points earned in this way. The site is being launched with a small selection of review articles that have been published recently in Ultrasound. It is hoped that one or more articles per issue can be used as CPD articles, and that a broad collection of articles can be accumulated as new issues are published. Please log into the BMUS website members’ area to register your details and look for relevant CPD articles. Many BMUS members and non-members make valuable contributions to the BMUS Annual Scientific Meeting by presenting papers and posters or running practical workshops. Some presenters then go on to make a permanent record of their work by publishing it in Ultrasound. Now, all contributors can have a discoverable record of their work via the Ultrasound pages of the SAGE website. This May issue of Ultrasound is accompanied by an online-only supplement which contains all abstracts and titles from the Annual Scientific Meeting held in Manchester in December 2014. You can find the supplement at http://ult.sagepub.com We begin this May issue with a report from Willits et al. on a very large retrospective study of unenhanced ultrasound scans of the liver. It seems that many of these scans were able to detect, but not characterise, focal liver lesions (FLL). There were more inconclusive scans in the outpatient cohort than in the GP cohort, and almost 50% of FLLs detected in cirrhotic livers were inconclusive. The results of this research will inform future NICE diagnostics guidance on the use of contrast agents. Clements et al. report on a study aimed at developing ultrasound criteria for the assessment of the internal jugular vein. They show that body position (sitting or supine) has a large impact on cross-sectional area, time average velocity and reflux measurements. Katie Johnson et al. report on a study of the relationship between temporomandibular joint effusion and a patient reported disability index of the jaw. The strong correlation suggests that the index might be used in clinical assessments in place of ultrasound measurements. The previous issue of Ultrasound in February was a special issue devoted to education and training in ultrasound. You may have noticed that this special issue was larger than usual. In fact, it could have been much larger, because there were far more articles submitted than we could possibly publish in a single issue. So in this May issue, we include those education and training articles that were delayed. Parker and Byass describe the implementation of an audit tool based on case review by peers that helped identify the development needs of sonographers and monitor the quality of the scanning service. Diane Dickson reports on a study of how interactive educational technologies may help sonography students relate theory to practice. Grace Carolan-Rees describes a cost model for an ultrasound virtual reality training simulator. It seems that in most circumstances, cost savings can be made by using the simulator rather than traditional practical training methods. Returning to the use of contrast in the detection of liver lesions, Obaro and Ryan review the grey scale and contrast-enhanced ultrasound appearances of a range of benign liver lesions. Finally, a case report by Greenall and Drage demonstrates the ultrasound features of sebaceous carcinoma of the lip and describes the normal anatomy of this area.

Setting up of ambulatory hysteroscopy service

There is an obvious trend towards developing ambulatory procedures in gynaecology with ambulatory hysteroscopy as its mainstay. In the recent years, the fast pace of modern technological advances in gynaecologic endoscopy, and particularly in the field of hysteroscopy, have been both thrilling and spectacular. Despite this, the uptake of operative hysteroscopy in ambulatory settings has been relatively slow. There is some apprehension amongst gynaecologists to embark on therapeutic outpatient hysteroscopy, and an organisational change is required to alter the mindset. Although there are best practice guidelines for outpatient hysteroscopy, there are unresolved issues around adequate training and accreditation of future hysteroscopists. Virtual-reality simulation training for operative hysteroscopy has shown promising preliminary results, and it is being aggressively evaluated and validated. This review article is an attempt to provide a useful practical guide to all those who wish to implement ambulatory hysteroscopy services in their outpatient departments.

Virtual Reality Simulation Training for Ebola Deployment.

Both virtual and hybrid simulation training offer a realistic and effective educational framework and opportunity to provide virtual exposure to operational public health skills that are essential for infection control and Ebola treatment management. This training is designed to increase staff safety and create a safe and realistic environment where trainees can gain essential basic and advanced skills.

Visual modality research in virtual and mixed reality simulation

Military organizations worldwide continue to invest heavily in research, development, and fielding of virtual and mixed reality simulations and simulators for training. However, the future fiscal environment will be challenging for both simulation as well as the US Army as a whole. Thus, wise design decisions must be made when developing virtual simulations for training. In order to optimize the effectiveness of these simulations, developers must employ trade-off analysis and scientific methods to derive empirical evidence, in order to ensure that the simulation under development is optimized to meet the training requirements, while still adhering to cost and schedule constraints. This paper specifically focuses on the task of employing the optimal visual modality in virtual and mixed reality simulations. This paper reviews the literature on training simulation benefits and taxonomy, and examines the training efficacy of virtual and mixed reality simulation. Major concepts and applications of virtual and mixed reality simulation training efficacy are discussed. A key component of virtual simulation, visual modality, is examined through a literature review and recommendations for visual display design parameters are provided.

The ScanTrainer obstetrics and gynaecology ultrasound virtual reality training simulator: A cost model to determine the cost viability of replacing clinical training with simulation training.

The aim of this study was to produce an economic cost model comparing the use of the Medaphor ScanTrainer virtual reality training simulator for obstetrics and gynaecology ultrasound to achieve basic competence, with the traditional training method. A literature search and survey of expert opinion were used to identify resources used in training. An executable model was produced in Excel. The model showed a cost saving for a clinic using the ScanTrainer of £7114 per annum. The uncertainties of the model were explored and it was found to be robust. Threshold values for the key drivers of the model were identified. Using the ScanTrainer is cost saving for clinics with at least two trainees per year to train, if it would take at least six lists to train them using the traditional training method and if a traditional training list has at least two fewer patients than a standard list.

Role of virtual reality simulation in endoscopy training.

Recent advancements in virtual reality graphics and models have allowed virtual reality simulators to be incorporated into a variety of endoscopic training programmes. Use of virtual reality simulators in training programmes is thought to improve skill acquisition amongst trainees which is reflected in improved patient comfort and safety. Several studies have already been carried out to ascertain the impact that usage of virtual reality simulators may have upon trainee learning curves and how this may translate to patient comfort. This article reviews the available literature in this area of medical education which is particularly relevant to all parties involved in endoscopy training and curriculum development. Assessment of the available evidence for an optimal exposure time with virtual reality simulators and the long-term benefits of their use are also discussed.

Home virtual reality simulation training: the effect on trainee ability and confidence with laparoscopic surgery

Home virtual reality simulation training: the effect on trainee ability and confidence with laparoscopic surgery

Virtual reality lead extraction as a method for training new physicians: a pilot study.

It is estimated that the demand for transvenous lead extraction (TLE) has reached an annual extraction rate of nearly 24,000 patients worldwide. Despite technologic advances, TLE still has the potential for significant morbidity and mortality. Complication rates with TLE directly parallel operator experience. However, obtaining adequate training during and postfellowship can be difficult. Given the potential for catastrophic complications and the steep learning curve (up to 300 cases) associated with this procedure, we sought to validate a virtual reality (VR) lead extraction simulator as an innovative training and evaluation tool for physicians new to TLE. We randomized eight electrophysiology fellows to VR simulator versus conventional training. We compared procedural skill competency between the groups using simulator competency, tactile measurements, markers of proficiency and attitudes, and cognitive abilities battery. Practical skills and simulator complications differed significantly between the VR simulator and conventional training groups. The VR simulator group executed patient preparation and procedure performance better than the conventional group (P < 0.01). All four fellows randomized to conventional training experienced a simulator complication (two superior vena cava [SVC] tears, three right ventricle [RV] avulsions) versus one fellow in the VR simulator group (one SVC tear) (P = 0.02). Tactile measurements revealed a trend toward excess pushing versus pulling forces among the conventionally trained group. The time for lead removal was also significantly higher in the conventional training group (12.46 minutes vs 5.54 minutes, P = 0.02). There was no significant difference in baseline or posttraining cognitive ability. We contend that the implementation of alternative training tools such as a VR simulation model will improve physician training and allow for an innovative pathway to assess the achievement of competency.

A Study of the Effect of Dyad Practice Versus That of Individual Practice on Simulation-Based Complex Skills Learning and of Students’ Perceptions of How and Why Dyad Practice Contributes to Learning

The aims of this study were (1) to explore the effectiveness of dyad practice compared with individual practice on a simulator for learning a complex clinical skill and (2) to explore medical students' perceptions of how and why dyad practice on a simulator contributes to learning a complex skill. In 2011, the authors randomly assigned 84 medical students to either the dyad or the individual practice group to learn coronary angiography skills using instruction videos and a simulator. Two weeks later, participants each performed two video-recorded coronary angiographies on the simulator. Two raters used a rating scale to assess the participants' video-recorded performance. The authors then interviewed the participants in the dyad practice group. Seventy-two (86%) participants completed the study. The authors found no significant difference between the performance scores of the two groups (mean±standard deviation, 68%±13% for individual versus 63%±16% for dyad practice; P=.18). Dyad practice participants noted that several key factors contributed to their learning: being equal-level novices, the quality of the cooperation between partners, observational learning and overt communication, social aspects and motivation, and meta-cognition. Dyad practice is more efficient and thus more cost-effective than individual practice and can be used for costly virtual reality simulator training. However, dyad practice may not apply to clinical training involving real patients because learning from errors and overt communication, both keys to dyad practice, do not transfer to clinical practice.

A 3D virtual reality simulator for training of minimally invasive surgery.

For the last decade, remarkable progress has been made in the field of cardiovascular disease treatment. However, these complex medical procedures require a combination of rich experience and technical skills. In this paper, a 3D virtual reality simulator for core skills training in minimally invasive surgery is presented. The system can generate realistic 3D vascular models segmented from patient datasets, including a beating heart, and provide a real-time computation of force and force feedback module for surgical simulation. Instruments, such as a catheter or guide wire, are represented by a multi-body mass-spring model. In addition, a realistic user interface with multiple windows and real-time 3D views are developed. Moreover, the simulator is also provided with a human-machine interaction module that gives doctors the sense of touch during the surgery training, enables them to control the motion of a virtual catheter/guide wire inside a complex vascular model. Experimental results show that the simulator is suitable for minimally invasive surgery training.

Virtual reality simulator for training on photoselective vaporization of the prostate with 980 nm diode laser and learning curve of the technique

ObjectiveThe utility of a virtual reality simulator for training of the photoselective vaporization of the prostate with diode laser was studied. Materials and methodsTwo experiments were performed with a simulator (VirtaMed AG, Zürich, Switzerland) with software for specific training in prostate vaporization in contact mode with Twister fiber (Biolitec AG, Jena, German). Eighteen surgeons performed ablation of the prostate (55cc) twice and compared the score obtained (190 points efficacy and 80 safety) in the second one of them by experience groups (medical students, residents, specialists). They also performed a spatial orientation test with scores of 0–6. After, six of these surgeons repeated 15 ablations of the prostate (55 and 70ml). Improvement of the parameters obtained was evaluated to define the learning curve and how experience, spatial orientation skills and type of sequences performed affects them. ResultsGlobal efficacy and safety score were different according to the grade of experience (P=.005). When compared by pairs, specialist-student differences were detected (p=0.004), but not specialist-resident (P=.12) or resident-student (P=.2). Regarding efficacy of the procedure, specialist-student (p=0.0026) and resident-student (P=.08) differences were detected. The different partial indicators in terms of efficacy were rate of ablation (P=.01), procedure time (P=.03) and amount of unexposed capsule (p=0.03). Differences were not observed between groups in safety (P=.5). Regarding the learning curve, percentage median on the total score exceeded 90% after performing four procedures for prostates of 55ml and 10 procedures for prostate glands of 70ml. This course was not modified by previous experience (resident-specialist; P=.6). However, it was modified according to the repetition sequence (progressive-random; P=.007). Surgeons whose spatial orientation was less than the median of the group (value 2.5) did not surpass 90% of the score in spite of repetition of the procedure. ConclusionSimulation for ablation of the prostate with contact diode laser is a good learning model with discriminative validity, as it correlates the metric results with levels of experience and skills. The sequential repetition of the procedure on growing levels of difficulty favors learning.

Single-Session Baseline Virtual Reality Simulator Scores Predict Technical Performance for Laparoscopic Colectomy: A Study in the Swine Model

Virtual reality (VR) simulation helps reducing the learning curve of laparoscopic colectomy. Moreover, it may be used to ascertain surgeons' pretraining skills. It was aimed to establish predictive validity of specific parameters gathered during VR simulation training on sigmoid colectomy and whether simulator parameters correlate with technical performance during the same operation in a swine model. Surgeons novice to laparoscopic colectomy underwent a single VR simulation session on sigmoid colectomy. Next, all participants performed a laparoscopic sigmoidectomy in the swine. Operations were recorded. Performance evaluation was conducted by 2 board-certified colorectal surgeons blinded to surgeons' simulator scores using an instrument specific to laparoscopic colectomy. For each participant, a mean score of specific skills was calculated. Linear regression analysis was used to identify simulator parameters that were best related to the score. The stepwise method was used to select parameters. The magnitude of the regression model was measured by the coefficient of determination (R(2)) value. The University of Sao Paulo Medical Center is a high-volume, public practice, university-affiliated hospital. A total of 14 first-year residents in digestive tract surgery were included. Analysis of variance demonstrated that the regression model was significant (p = 0.0001), and an association between simulation scores and specific skills was confirmed. The R(2) value was 99%. The VR simulator parameters that strongly correlated with specific skills during laparoscopic colectomy in the swine were safe use of electrosurgery/energy device and safety of medial-to-lateral dissection. A single VR simulation session for novice surgeons in the sigmoid colectomy module generates baseline scores that highly correlated with performance of specific skills during a laparoscopic colectomy in the swine. This information may be useful in an attempt to tailor VR simulator practice according to a surgeon's needs.

Validation of the ArthroS virtual reality simulator for arthroscopic skills.

Virtual reality simulator training has become important for acquiring arthroscopic skills. A new simulator for knee arthroscopy ArthroS™ has been developed. The purpose of this study was to demonstrate face and construct validity, executed according to a protocol used previously to validate arthroscopic simulators. Twenty-seven participants were divided into three groups having different levels of arthroscopic experience. Participants answered questions regarding general information and the outer appearance of the simulator for face validity. Construct validity was assessed with one standardized navigation task. Face validity, educational value and user friendliness were further determined by giving participants three exercises and by asking them to fill out the questionnaire. Construct validity was demonstrated between experts and beginners. Median task times were not significantly different for all repetitions between novices and intermediates, and between intermediates and experts. Median face validity was 8.3 for the outer appearance, 6.5 for the intra-articular joint and 4.7 for surgical instruments. Educational value and user friendliness were perceived as nonsatisfactory, especially because of the lack of tactile feedback. The ArthroS™ demonstrated construct validity between novices and experts, but did not demonstrate full face validity. Future improvements should be mainly focused on the development of tactile feedback. It is necessary that a newly presented simulator is validated to prove it actually contributes to proficiency of skills.