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The internal validity of arthroscopic simulators and their effectiveness in arthroscopic education

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The purpose of this systematic review was to identify standard procedures for the validation of arthroscopic simulators and determine whether simulators improve the surgical skills of users.


Arthroscopic simulator validation studies and randomized trials assessing the effectiveness of arthroscopic simulators in education were identified from online databases, as well as, grey literature and reference lists. Only validation studies and randomized trials were included for review. Study heterogeneity was calculated and where appropriate, study results were combined employing a random effects model.


Four hundred and thirteen studies were reviewed. Thirteen studies met the inclusion criteria assessing the construct validity of simulators. A pooled analysis of internal validation studies determined that simulators could discriminate between novice and experts, but not between novice and intermediate trainees on time of completion of a simulated task. Only one study assessed the utility of a knee simulator in training arthroscopic skills directly and demonstrated that the skill level of simulator-trained residents was greater than non-simulator-trained residents.


Excessive heterogeneity exists in the literature to determine the internal and transfer validity of arthroscopic simulators currently available. Evidence suggests that simulators can discriminate between novice and expert users, but discrimination between novice and intermediate trainees in surgical education should be paramount. International standards for the assessment of arthroscopic simulator validity should be developed to increase the use and effectiveness of simulators in orthopedic surgery.

Level of evidence

Diagnostic study, Level III.

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Correspondence to Jesse Alan Slade Shantz.

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Slade Shantz, J.A., Leiter, J.R.S., Gottschalk, T. et al. The internal validity of arthroscopic simulators and their effectiveness in arthroscopic education. Knee Surg Sports Traumatol Arthrosc 22, 33–40 (2014).

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