ORIGINAL REPORTS

Transpedicular Approach on a Novel

Spine Simulator: A Validation Study

David Fürst, PhD,* Marianne Hollensteiner, PhD,* Stefan Gabauer, MSc,* Benjamin Esterer, MSc,*
Klemens Trieb, MD,† Felix Eckstein, MD,‡ and Andreas Schrempf, PhD*

*
Research Group for Surgical Simulators Linz, Upper Austria University of Applied Sciences, Linz, Austria;
†
Department of Orthopedics, Klinikum Wels-Grieskirchen, Wels, Austria; and ‡Institute of Anatomy,
Paracelsus Medical University Salzburg & Nuremberg, Salzburg, Austria

OBJECTIVE: The popularity of simulation in the medical
field has increased dramatically over the last decades.
However, the majority of studies focused on laparoscopic
or other endoscopic procedures. In this study, participants
performed an image-guided surgery task on a novel spine
simulator. Face, content, construct, and concurrent validity
were examined.
DESIGN: A surgical access through both pedicles (trans-
pedicular) into the vertebral body of artificial L3 vertebrae
was performed. Questionnaires, a simulation-based per-
formance score, and a specialist rating were used to evaluate
the various forms of validity.
SETTING: Klinikum Wels-Grieskirchen, Wels, Austria;
tertiary hospital
PARTICIPANTS: According to their expertise in image-
guided surgery and pedicle tool insertions, 43 participants
were subdivided into 3 groups: 22 novices, 12 intermedi-
ates, and 9 experts.
RESULTS: Of the novice group, the vast majorities were
impressed with the attractiveness and the general appearance
of the simulator. The majority of intermediates (92%) and
experts (89%) would recommend the simulator to others.
According to a simulation-based performance score, experts
performed significantly better than novices (p ¼ 0.001,
d ¼ 1.52) and intermediates (p ¼ 0.01, d ¼ 1.26). The
association between the simulation-based performance score
and the specialist rating was strong (R ¼ 0.86, p o 0.01).
CONCLUSIONS: The novel spine simulator provides an
applicable tool for the training of image-guided surgery
skills in a realistic design. Its simulation-based assessment
This work was supported by the Austrian Research Promotion Agency (FFG)
within the program line Cooperation & Innovation (COIN) and project number
845436.
Correspondence: Inquiries to David Fürst, Research Group for Surgical Simulators
Linz, Upper Austria University of Applied Sciences, Garnisonstr. 21, 4020, Linz,
Austria; e-mail: david.fuerst@fh-linz.at
score classifies different levels of expertise accurately.
( J Surg Ed ]:]]]-]]]. J C 2018 Association of Program
Directors in Surgery. Published by Elsevier Inc. All rights
reserved.)
KEY WORDS: surgical simulation, validity, transpedicular
approach, specialist rating
COMPETENCIES: Patient Care, Medical Knowledge, Prac-
tice-Based Learning and Improvement
INTRODUCTION
Simulation covers a set of conditions that are created
artificially to experience something that does exist in
reality.1 For more than 50 years, the flight industry has
used simulation to increase pilot performance and passen-
gers’ safety. In the last decades, the popularity of simulation
in the medical field increased dramatically. However, the
majority of studies and reviews showing a benefit in surgical
training focused on laparoscopy or endoscopic procedures2
while simulation in the field of orthopedics lags behind.3
When discussing different simulator models, criteria such as
fidelity, validity, and reliability should be taken into
account.4 Bench models or box trainers are summarized
under the expression “low-fidelity” simulators. They allow
operating on physical objects (e.g., artificial anatomical
structures) with real surgical instruments which offers more
or less realistic haptic feedback. While low-fidelity trainers
are relatively inexpensive, their ability of defining profi-
ciency-based criteria is limited.5 In contrast, procedural
trainers or virtual reality systems are often referred to as
“high-fidelity” simulators. They are characterized by a more
complex technology, a higher degree of realism, and
extensive feedback possibilities. However, such systems are
very cost intensive.5
Regardless of fidelity, a simulation-based assessment
should be valid and reliable. This means that it should

Journal of Surgical Education  & 2018 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 1
Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jsurg.2018.01.002
measure consistently what it was intended to measure
across repeated assessments.6 To achieve this, various
forms of validity and reliability are defined in the
literature.6-8 Face and content validity of a simulator are
often examined by questionnaires: while novices answer
questions about the general appearance of a simulator,
experienced surgeons assess it′s content-related suitabil-
ity.9 To demonstrate construct validity, the simulator
should be able to discriminate between different levels of
expertise.8 Concurrent validity describes the extent to
which the results of the simulation-based assessment
correlate with the gold standard assessment, such as the
Objective Structured Assessment of Technical Skills
(OSATS).10 It consists of an operation- or task-specific
checklist and a global rating scale.7
As a training modality for spine surgery, a novel simulator
was developed. To practice image-guided surgery skills, the
transpedicular approach can be simulated. The objective of
this study was to examine its face, content, construct, and
concurrent validity.

MATERIALS AND METHODS

Simulator
The simulator consisted of a patient dummy, an electro-
magnetic tracking system (Aurora, NDI, Waterloo, Can-
ada), a foot pedal, and a computer with monitor for
operating the simulation software (Fig. 1). The patient
dummy was made of silicone rubber and has a rectangular
cutout at the thoracolumbar spine. Beneath this cutout, 3
exchangeable artificial vertebrae (in this study L2-L4)
were constrained within a semirigid clamping device. The
trabecular structure within the artificial vertebrae was
mechanically and morphologically validated as published
previously.11
Real surgical instruments were equipped with sensor coils
and their position and orientation were determined with the
electromagnetic tracking system. By pressing the foot pedal,
the simulation software generated simulated fluoroscopic
images in anterior-posterior (AP) and mediolateral (ML)
direction presented on the monitor (Fig. 2). For this study,
the focal points of the simulated x-ray sources (AP and ML)
were set automatically.
Subjects
The simulator was provided to a regional hospital
(Klinikum Wels-Grieskirchen) in Wels, Austria, where
43 participants from various medical departments were
recruited. First, each participant signed an informed
consent form concerning confidential usage of personal
data. Then, a short questionnaire assessing the task-
specific expertise of each participant was applied. Based
on the answers given, the participants were divided
FIGURE 1. Simulator for minimally invasive spine surgery consisting of
a patient phantom (A), an electromagnetic tracking system (B), a foot
pedal (C), and a monitor (D).
into 3 groups: A novice group (n ¼ 22), consisting of
participants who had no or little experience in pedicle tool
insertions or image-guided surgery, an intermediate group
(n ¼ 22) who had at least assisted in pedicle tool
insertions as well as image-guided surgery, and an expert
group (n ¼ 9), comprising participants with a high level of
expertise (active and passive) in pedicle tool insertions and
image-guided surgery.
Surgical Procedure
Each participant had to perform a bone access through both
pedicles (transpedicular) into the vertebral body of an
artificial L3 vertebra. First, all participants received an oral
presentation that included detailed instructions on each
task. Initially, a 6 degree-of-freedom probe (NDI, Waterloo,
Canada) with a rigid metal tip was used to localize the
pedicle. Then, an 11-gauge osteo-introducer-tool (Med-
tronic, Minneapolis) with a diamond-tipped stylet was
penetrated through artificial skin, muscle and bone tissue,
until a sufficient insertion depth was reached. Each partic-
ipant was free to decide the number and times of acquiring
simulated projections as well as the time when a task was
finished. Each participant was supported by a member of

2 Journal of Surgical Education  Volume ]/Number ]  ] 2018

 FIGURE 2. Screenshot of the operating software showing the simulated projection images in AP (left) and ML (right) direction.
the development team in operating the software (e.g., taking
pictures).
Assessment
To examine the face and content validity, questionnaires
with a 5-point Likert scale (adopted from Xiao et al.9) were
used. The participants were asked to complete these
immediately after completing the simulation procedure.
While novices answered questions about the relative realism
of the simulator (face validity—Table 1), intermediates and
experts rated its appropriateness as a surgical training tool
(content validity—Table 2).
To evaluate the construct validity, a simulation-based
performance score was calculated for each insertion side
(Table 3) and compared between the 3 groups. For this
purpose, a custom analysis software was programed using
Matlab (Matlab R2015b, The MathWorks, Natick). Dur-
ing each of the 4 tasks (localization and insertion on each
side), the position and orientation of the particular tool were
recorded with a sample rate of 40 Hz. Based on the
resulting trajectory, parameters such as the number of
instrument movements nAoM and the length of the traveled
instrument path xtool were calculated and provided a
TABLE 1. Questionnaire for the Assessment of the Simulator’s Face Validity (1 ¼ Strongly Disagree/Not Realistic, 3 ¼ Neither
Agree or Disagree/Neutral, and 5 ¼ Strongly Agree/Very Realistic)
Questions
How would you rate the attractiveness of this spine simulator?
Do you think that having this spine simulator would encourage you to
practice your image-guided surgery skills more often?
I would like to have a spine simulator of my own.
How would you evaluate the general appearance of the spine simulator
(proportions of the patient phantom, the structure of the simulator, …)?
Journal of Surgical Education  Volume ]/Number ]  ] 2018
contribution to the overall performance score. Such profi-
ciency metrics have already been used previously for validating
the Imperial College Surgical Assessment Device (ICSAD)12
and are commonly used for evaluating simulators for laparo-
scopic surgery.13 The number of projections (nAP for both
tasks, nML only for insertion) and the duration (t) of each task
were also included in computing the score. In the study of
Tonetti et al.14 the number of projections also was already
used as an assessment parameter. The smaller these metrics,
the higher the individual scores. Instrument penetration into
the spinal canal was defined as a fatal error.
For the instrument insertion task, an efficiency index was
additionally implemented. For calculation, a 3-dimensional
region of interest (ROI) with the shape of a bulb was
defined for each insertion side (Fig. 3). The index was then
calculated by dividing the number of samples within the
bulb-shaped ROI with the overall sample number. The
more the instrument was moved within the ROI, the higher
the calculated index and thus the individual score. In
contrast, samples detected within a canal-specific ROI (red
zone) set the insertion score to 0. However, the usage of a
tracking system always induces slight inaccuracies. There-
fore, a visual control of each vertebra was additionally
performed to confirm penetrations into the spinal canal.
Rating
1 2 3 4 5
⃝ ⃝ ⃝ ⃝ ⃝
⃝ ⃝ ⃝ ⃝ ⃝
⃝ ⃝ ⃝ ⃝ ⃝
⃝ ⃝ ⃝ ⃝ ⃝
3
TABLE 2. Questionnaire for the Assessment of the Simulator’s Content Validity (1 ¼ Strongly Disagree/Not Realistic, 3 ¼ Neither
Agree or Disagree/Neutral, and 5 ¼ Strongly Agree/Very Realistic)
Rating

Questions 1 2 3 4 5
How would you rate this spine simulator for training in an ergonomic manner? ⃝ ⃝ ⃝ ⃝ ⃝
(e.g., ensuring proper manipulation angle/elevation angle/instrument scaling)
Do you consider this spine simulator useful for practicing image-guided surgery skills? ⃝ ⃝ ⃝ ⃝ ⃝
Did you consider this spine simulator easy to use? ⃝ ⃝ ⃝ ⃝ ⃝
Would you recommend such a spine simulator to others? ⃝ ⃝ ⃝ ⃝ ⃝
The spine simulator contains all the important procedural steps that are necessary ⃝ ⃝ ⃝ ⃝ ⃝
for a surgeon to learn the procedure.

Minor medial breaches were considered correct. The
weighting of all performance parameters was determined
in coordination with the specialist.
To establish concurrent validity, the performance of each
participant was assessed by a specialist (head of the depart-
ment of orthopedic surgery) who did not participate himself
in the study as an active participant. Using a video camera
and screen capture software, the individual fluoroscopic
images were recorded and provided for assessment. The
resulting film material was anonymized before rating, to
warrant blinded evaluation. The specialist used a task-
specific checklist and a global rating scale (OSATS). While
the checklist had 10 items (1 point for each correctly
performed action—Table 4), the global rating scale con-
sisted of 7 variables marked on a 5 point Likert scale
corresponding to a maximum of 35 points. According to the
specialist rating, a maximum of 45 points could be reached
for each insertion side. If the spinal canal was penetrated,
the checklist score was set to 0 while the global rating scale
resulted in 7 points (¼very bad performance).
Statistical Analysis
All statistical analyses were performed using SPSS (SPSS
Statistics 22, IBM, Amonk), while all plots were generated
with Matlab (Matlab R2015b, The MathWorks, Natick).
To compare the performance parameters between both
approaches, the paired t-test or a nonparametric equivalent
(Wilcoxon signed-rank test) was used. In contrast, differ-
ences between groups were detected using the unpaired
Student t-test or the nonparametric Mann-Whitney U test.
To measure the strength of a statistical relationship, the
effect size (Cohen d or r) was calculated. Prior to that, each
group data was checked for normality (Shapiro-Wilk test)
and variance homogeneity (Levene test). The association
between the simulation-based performance score and the
expert rating was evaluated using Pearson test for linear
correlation. Unless otherwise stated, a significance level of
5% was chosen.
RESULTS
Face and Content Validity
The average rating on the simulators’ face validity is shown
in Table 5. Almost all novices rated the attractiveness (95%)
as well as the general appearance (91%) of the simulator as
good/realistic (4 points) to excellent/very realistic (5 points).
Further, 86% stated they would practice their image-guided
surgery skills more often when having access to such a
simulator and more than 59% stated they would like to own
such a training modality.

TABLE 3. Structure of the Simulation-Based Performance

Score. Depending on Its Importance, a Maximum of 3, 6, or
9 Points Was Awarded for Each Parameter Which Resulted in a
Maximum Subscore of 18 and 30 Points, Respectively, for
Localization and Insertion. Thus, a Maximum Performance
Score of 48 Points Could Be Achieved for Each Side
Parameter Localization Insertion
nAoM 3 3
x tool ðmÞ 6 6
nAP 3 3
nM L - 3
tðsÞ 6 6
EI - 9 FIGURE 3. Example of left (novice, EI ¼ 0.47) and right (expert, EI ¼
Overall max. 18 max. 30 0.97) insertion approach showing the tool tip trajectories (A), the bulb-
shaped ROI’s (B) and the critical regions for detecting penetrations into
EI, efficiency index. the spinal canal (C). EI, efficiency index.

4 Journal of Surgical Education  Volume ]/Number ]  ] 2018

TABLE 4. Task-Specific Checklist for Transpedicular Bone Access. For Each Correctly Performed Action 1 Point is Scored Resulting in
a Maximum of 10 Points
No. Procedural Step Correct Incorrect
1 Find spinous process under skin ⃝ ⃝
2 Selects appropriate instrument for pedicle localization ⃝ ⃝
3 Correct localization of the pedicle ⃝ ⃝
4 Selects appropriate insertion instrument ⃝ ⃝
5 Chooses correct starting positions 9 to 11-o’ clock (left side) and 1 to 3-o’clock (right side) ⃝ ⃝
6 Advances instrument until getting in contact with bone (controlled by imaging) ⃝ ⃝
7 Advances instrument into first half of pedicle (controlled by imaging) ⃝ ⃝
8 Advances instrument to margin of pedicle (controlled by imaging) ⃝ ⃝
9 Advances instrument through back wall of vertebral body (3 to 4 mm after ⃝ ⃝
back trailing edge, controlled by imaging)
10 Finished transpedicular approach successfully ⃝ ⃝

TABLE 5. Average Rating on the Simulators’ Face Validity Assessed by the Novice Group (n ¼ 22)
Questions Average Rating
How would you rate the attractiveness of this spine simulator? 4.59
Do you think that having this spine simulator would encourage you to practice 4.59
your image-guided surgery skills more often?
I would like to have a spine simulator of my own. 3.45
How would you evaluate the general appearance of the spine simulator 4.41
(proportions of the patient phantom, the structure of the simulator, … )?

TABLE 6. Average Rating on the Simulators’ Content Validity Assessed by Intermediates (n ¼ 12) and Experts (n ¼ 9)
Average Rating

Questions I E
How would you rate this spine simulator for training in an ergonomic manner? 4.34 4.56
(e.g., ensuring proper manipulation angle/elevation angle/instrument scaling)
Do you consider this spine simulator useful for practicing image-guided surgery skills? 4.50 4.78
Did you consider this spine simulator easy to use? 4.58 4.56
Would you recommend such a spine simulator to others? 4.50 4.67
The simulator contains all the important procedural steps that are necessary 4.08 4.11
for a surgeon to learn the procedure.
I, intermediates; E, experts.

TABLE 7. Comparison of Left and Right Approach Based on Absolute Values (Mean ± SD) of the Performance Parameters
Parameter Left Right p Value Effect Size
*
nAoM 36.7 ± 15.1 33.6 ± 29.5 0.024 0.34
x tool ðmÞ 1.68 ± 0.68 1.45 ± 0.83 0.018* 0.36
nAP 13.0 ± 7.8 13.6 ± 10.7 0.907 -
nM L 9.3 ± 6.0 10.3 ± 7.6 0.454 -
tðsÞ 178.6 ± 82.6 154.2 ± 118.8 0.022* 0.35
EI 0.35 ± 0.12 0.47 ± 0.13 0.000* 0.63
EI, efficiency index.
p o 0.05.

Journal of Surgical Education  Volume ]/Number ]  ] 2018 5

TABLE 8. Side-Specific Simulation-Based Performance Scores and Specialist Ratings for Novices (n ¼ 22), Intermediates (n ¼ 12),
and Experts (n ¼ 9). The Penetrations into the Spinal Canal Are Indicated in Parentheses
Performance Score Specialist Rating

Group Left Right Left Right

Novices 16.1 ± 10.9 (16) 14.0 ± 10.7 (19) 19.7 ± 17.4 11.9 ± 12.5
Intermediates 18.0 ± 11.8 (6) 18.2 ± 10.4 (10) 22.7 ± 16.7 13.3 ± 14.8
Experts 26.4 ± 9.8 (1) 29.2 ± 10.9 (2) 38.0 ± 12.0 34.3 ± 15.6

The responses to asking whether the simulator was an
appropriate training tool were entirely positive (Table 2).
Almost all intermediates (92%) and experts (100%) were
satisfied with the ergonomics of the simulator. They
declared the simulator was easy to use (92% and 100%),
useful for practicing image-guided surgery skills (92% and
100%), and said they would recommend the simulator to
others (92% and 89%). Finally, 83% of the intermediates
and 78% of the experts confirmed that the simulator
contained all important procedural steps that were necessary
to learn the surgical procedure (Table 6).
In view of the overall simulation-based performance score
(Fig. 4), the experts performed significantly better than the
novices (p ¼ 0.001, d ¼ 1.52) and intermediates (p ¼ 0.01,
d ¼ 1.26). The performance was, however, not significantly
different (p ¼ 0.301) between the novices and intermedi-
ates. The overall specialist rating confirmed these results
(Fig. 5) demonstrating a significantly better performance of
the experts compared with the novices (p ¼ 0.003, r ¼
0.55) and intermediates (p ¼ 0.012, r ¼ 0.55), but no
significant difference in the performance of the novices and
intermediates (p ¼ 0.790).

Left vs Right Approach Concurrent Validity

When comparing the performance parameters of the second
approach with the first (Table 7), participants tended to
proceed quicker making less movements. The number of
projections, however, remained nearly constant.
Construct Validity
Comparing the simulation-based performance score and the
specialist rating, the relation between both assessments was
apparent (R ¼ 0.86, p o 0.01). The linear regression plot
(Fig. 6) further shows that the highest scores were primarily
reached by experts (upper right corner) while novices and
intermediates shared the lower left.

The simulation-based performance scores (penetrations into

the spinal canal in parentheses) and the specialist ratings for
each insertion side are summarized in Table 8. According to
these results, the level of experience of the participants had a
great impact on the success of the surgical procedure. The
novice group recorded numerous penetrations into the
spinal canal on both sides, while the intermediates had
severe problems on the right side only. The experts group
recorded the fewest number of violations on both sides.
DISCUSSION
The purpose of the current study was to validate a novel
spine simulator based on a percutaneous transpedicular
approach. In contrast to a virtual reality system,15 the tactile
experience was generated by valid artificial structures. Based
on the ratings of novices, intermediates and experts one can
conclude that the novel spine simulator provides a realistic

FIGURE 4. Overall simulation-based performance scores for novices FIGURE 5. Overall specialist rating for novices (n ¼ 22), intermedi-
(n ¼ 22), intermediates (n ¼ 12), and experts (n ¼ 9). ates (n ¼ 12), and experts (n ¼ 9).

6 Journal of Surgical Education  Volume ]/Number ]  ] 2018


FIGURE 6. Linear regression relating specialist rating to simulation-
based performance score.
design and can be readily applied for training image-guided
surgery skills. For the novice group, the wish to own a
simulator was rated low, potentially because within the
novice group surgeons from different medical departments
were included. Therefore, their enthusiasm for owning such
a complex device dedicated to orthopedic surgery was
limited, although they were convinced of its usefulness.
The number of penetrations into the spinal canal, which
was initially defined as a fatal error, was very high amongst
novices and intermediates. This suggests that the procedure
of percutaneous transpedicular bone access and thus, image-
guided interventions are quite challenging and that
simulator training may be very helpful. In our setting, a
high-fidelity design with a combination of realistic tactile
force-feedback and eye-hand coordination was chosen. Such
psychomotor skills effectively develop through repetitive
training,3 and therefore participants of the novice group
were partially overstrained with the task. Consequently, the
overall performance score of many participants was just that
given for pedicle localization. The spread of the overall
simulation-based performance score was hence relatively
large and the same applied for the specialist rating. A clear
majority of novices and intermediates (particularly their
right insertion approach) were rated with only 7 (of 45)
points. Since no feedback was provided to participants after
their first approach (left), they tended to proceed quicker on
the second side (right), maybe with less carefulness. While
single penetrations happened almost exclusively during the
second approach, the vast majority of participants who
penetrated into the spinal canal on the first side did so on
the second side. Nevertheless, the simulation-based per-
formance score distinguished between different levels of
expertise and displayed a relatively high correlation with the
independent specialist ratings.
Apart from various types of validity, this study also
demonstrated how difficult the combined use of surgical
skills actually is. Tactile force-feedback and eye-hand
coordination are basic orthopedic skills required for many
surgical interventions. Their isolated training on simple
Journal of Surgical Education  Volume ]/Number ]  ] 2018
modalities16 prior to the performance on high-fidelity
simulators could be a more efficient approach for improving
task-specific psychomotor skills—particularly for novices,
since the simulator fidelity should comply with the trainees’
level of experience.17 Such a setting would also allow the
assessment of a previously performed skills course using a
validated simulator.18
The present study has some limitations: First, participants
from only 1 institution were included resulting in a
relatively small number of experts. Second, only 1 inde-
pendent rating was conducted and therefore interrater
reliability could not be assessed. Further, all participants
performed the surgical procedure only once and therefore
the documentation of a task-specific learning curve was not
possible. Also, the performance of novices and intermediates
was similar, so that a different definition of intermediates
may have provided a better differentiation between the
participant groups.
CONCLUSIONS
The findings of this study show that the novel simulator
provides an applicable tool for the training of image-guided
surgery skills in a realistic design. Based on a simulation-
based performance score, the assessment can distinguish
between different levels of expertise. Moreover, surgical
trainees can improve essential psychomotor skills without
temporal limitations outside the operating room.
REFERENCES
1. Hornby AS. Oxford Advanced Learner’s Dictionary.
8th Ed, Oxford University Press, 2013.
2. Davies J, Khatib M, Bello F. Open surgical simulation
—a review. J Surg Educ. 2013;70:618-627. http://dx.
doi.org/10.1016/j.jsurg.2013.04.007.
3. Thomas GW, Johns BD, Marsh JL, Anderson DD.
A review of the role of simulation in developing and
assessing orthopaedic surgical skills. Iowa Orthop J.
2014;34:181. http://dx.doi.org/10.1515/folmed-2017-
0039.
4. Evgeniou E, Walker H, Gujral S. The role of
simulation in microsurgical training., J Surg Educ,
2017. http://dx.doi.org/10.1016/j.jsurg.2017.06.032.
5. Fairhurst K, Strickland A, Maddern GJ. Simulation
speak. J Surg Educ. 2011;68:382-386. http://dx.doi.
org/10.1016/j.jsurg.2011.03.003.
6. Van Nortwick SS, Lendvay TS, Jensen AR,
Wright AS, Horvath KD, Kim S. Methodologies for
establishing validity in surgical simulation studies.
7
 Surgery. 2010;147:622-630. http://dx.doi.org/10.1016/
j.surg.2009.10.068.
7. Moorthy K, Munz Y, Sarker SK, Darzi A. Objective
assessment of technical skills in surgery. Br Med J.
2003;327(7422):1032. http://dx.doi.org/10.1136/bmj.
327.7422.1032.
8. Tay C, Khajuria A, Gupte C. Simulation training: a
systematic review of simulation in arthroscopy and
proposal of a new competency-based training frame-
work. Int J Surg (London, England). 2014;12:626-633.
http://dx.doi.org/10.1016/j.ijsu.2014.04.005.
9. Xiao D, Jakimowicz JJ, Albayrak A, Buzink SN,
Botden SMBI, Goossens RHM. Face, content, and
construct validity of a novel portable ergonomic
simulator for basic laparoscopic skills. J Surg Educ.
2014;71:65-72. http://dx.doi.org/10.1016/j.jsurg.2013.
05.003.
10. Martin J, Regehr G, Reznick R, et al. Objective
structured assessment of technical skill (osats) for surgical
residents. Br J Surg. 1997;84(2):273-278. http://dx.doi.
org/10.1046/j.1365-2168.1997.02502.x.
11. Fuerst D, Senck S, Hollensteiner M, et al.
Characterization of synthetic foam structures used to
manufacture artificial vertebral trabecular bone. Mater
Sci Engin C Mater Biol Appl. 2017;76:1103-1111.
http://dx.doi.org/10.1016/j.msec.2017.03.158.
12. Hayter MA, Friedman Z, Bould MD, et al. Validation
of the imperial college surgical assessment device
(icsad) for labour epidural placement. Can J Anesth.
8 Journal of Surgical Education  Volume ]/Number ]  ] 2018
2009;56(6):419. http://dx.doi.org/10.1007/s12630-
009-9090-1.
13. Alaker M, Wynn GR, Arulampalam T. Virtual reality
training in laparoscopic surgery: a systematic review &
meta-analysis. Int J Surg. 2016;29:85-94. http://dx.
doi.org/10.1016/j.ijsu.2016.03.034.
14. 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. http://dx.doi.org/10.1016/
j.otsr.2009.07.005.
15. Gasco J, Patel A, Ortega-Barnett J, et al. Virtual
reality spine surgery simulation: an empirical study
of its usefulness. Neurol Res. 2014;36(11):968-973.
http://dx.doi.org/10.1179/1743132814y.0000000388.
16. Hohn EA, Brooks AG, Leasure J, et al. Development
of a surgical skills curriculum for the training and
assessment of manual skills in orthopedic surgical
residents. J Surg Educ. 2015;72(1):47-52. http://dx.
doi.org/10.1016/j.jsurg.2014.06.005.
17. Aggarwal R, Mytton OT, Derbrew M, et al. Training
and simulation for patient safety. Qual Saf Health
Care. 2010;19(Suppl 2):i34-i43. http://dx.doi.org/
10.1136/qshc.2009.038562.
18. Egol KA, Phillips D, Vongbandith T, Szyld D, Strauss EJ.
Do orthopaedic fracture skills courses improve resident
performance? Injury. 2015;46(4):547-551. http://dx.doi.
org/10.1016/j.injury.2014.10.061.