ORIGINAL REPORTS Current Status of Simulation-based Training Tools in Orthopedic Surgery: A Systematic Review Michael Morgan, BSc,* Abdullatif Aydin, BSc, MBBS, † Alan Salih, BSc, MBBS, ‡ Shibby Robati, MRCS, MSc, ‡ and Kamran Ahmed, PhD, FRCS † * School of Medicine, King’s College London, London, United Kingdom; † MRC Centre for Transplantation, Guy’s Hospital, King’s College London, London, United Kingdom; and ‡ Department of Orthopedic Surgery, East Sussex Healthcare NHS Trust, Eastbourne, United Kingdom OBJECTIVE: To conduct a systematic review of orthopedic training and assessment simulators with reference to their level of evidence (LoE) and level of recommendation. DESIGN: Medline and EMBASE library databases were searched for English language articles published between 1980 and 2016, describing orthopedic simulators or validation studies of these models. All studies were assessed for LoE, and each model was subsequently awarded a level of recommenda- tion using a modified Oxford Centre for Evidence-Based Medicine classification, adapted for education. RESULTS: A total of 76 articles describing orthopedic simulators met the inclusion criteria, 47 of which described at least 1 validation study. The most commonly identified models (n ¼ 34) and validation studies (n ¼ 26) were for knee arthroscopy. Construct validation was the most frequent validation study attempted by authors. In all, 62% (47 of 76) of the simulator studies described arthro- scopy simulators, which also contained validation studies with the highest LoE. CONCLUSIONS: Orthopedic simulators are increasingly being subjected to validation studies, although the LoE of such studies generally remain low. There remains a lack of focus on nontechnical skills and on cost analyses of orthopedic simulators. ( J Surg Ed ]:]]]-]]]. J C 2017 Associ- ation of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: orthopedic surgery, simulation, training, systematic review COMPETENCIES: Patient Care, Practice-Based Learning and Improvement, Interpersonal and Communication Skills INTRODUCTION Halstead’s method of “see one, do one, teach one” has traditionally been the preferred method of surgical training. 1 Learning as an “apprentice” in the operating room (OR) was the principal method of gaining skills at any level of a surgical trainee’s learning curve, until relatively recently. 1 With increased focus on patient safety, heightened patient expectations, and working time restrictions on weekly working hours, the Halsteadian method of training is now less applicable. 2,3 The successful implementation of simu- lation within the military and the aviation industries has paved the way for simulation-enhanced training in surgery. 3,4 The benefits of simulation training in the current climate are recognized by most surgical specialties, and increasing numbers of simulators have been developed as a result. 5 Orthopedic simulation has generally lagged behind other specialties, with fewer validated simulators available, though this trend is now changing. 5 Surgical simulators may be divided into several categories, including synthetic bench, animal and human cadaver models, and computer-assisted “virtual reality” (VR) simu- lators. Before these can be used for training and assessment, they must initially undergo a multiparametric assessment of validity. 6,7 The aim of this study is to identify all of the orthopedic simulators described in the literature and review their validity. METHODS Search Methods The EMBASE and MEDLINE databases were searched for articles that described orthopedic training models or simu- lators between 1980 and March 2016. The search strategy Correspondence: Inquiries to Abdullatif Aydin, BSc (Hons), MBBS, MRC Centre for Transplantation, 5th Floor Southwark Wing, Guy’s Hospital, King’s College London, London, London SE1 9RT, United Kingdom; e-mail: abdullatif.aydin@kcl.ac.uk Journal of Surgical Education  & 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved. 1931-7204/$30.00 http://dx.doi.org/10.1016/j.jsurg.2017.01.005 1