Table 4 Study descriptions

Andersen et al. [13]

21 (14 novices, 7 experts)

Visualise, palpating spheres on anatomical landmarks in the shoulder

No additional training

Visualise, palpating spheres on anatomical landmarks in VR

Time to complete exercise, number of collisions, maximum depth of collision, paths travelled by camera and probe

SS reduction in time (p = 0.03), path distance (p = 0.02) and depth of collisions (p = 0.02) for VR group. Number of collisions not SS in difference (p = 0.07).

Banaszek et al. [18]

40 (all novices)

Perform diagnostic knee arthroscopy and probing examination

Control 1: perform simulated task on benchtop simulator

Control 2: no additional training

Perform diagnostic arthroscopy on both simulators and cadaver, perform medial meniscectomy on cadaver

GRS scores, procedure-specific checklist, time per task, motion analysis

Both simulator groups showed improvement compared to control in all outcomes. VR group performed SS better than benchtop in lab and on cadaver (p = 0.02).

Blumstein et al. [25]

17 (all novices)

Perform tibial shaft fracture IM nailing

Read printed instructions on surgical technique for procedure

Perform tibial shaft fracture IM nailing on benchtop model

GRS and procedure-specific checklist

SS higher GRS (p = 0.001) and increase in correctly completed steps (p = 0.008) in VR group.

Cannon et al. [19]

48 (all intermediates)

Visualise, probe anatomical structures in the knee (must achieve level of proficiency to progress)

No additional training

Perform diagnostic arthroscopy on live patient, within 25 min

GRS, procedure-specific checklist (visualisation scale and probing scale)

VR group had SS higher scores in procedure-specific checklist (p = 0.031), but not GRS (p = 0.061). Visualisation score did not have SS difference (p = 0.34). Control group was faster but performed less correct steps.

Cychosz et al. [20]

43 (all novices)

Complete FAST modules on tracking, periscoping, palpation and collecting stars. Perform knee arthroscopy

No additional training

Perform diagnostic knee arthroscopy in VR

Camera path length, cartilage damage, time to complete

VR group had SS higher overall scores (p = 0.046) and shorter path length (0.0274). Time and damage not SS in difference (p = 0.3, p = 0.4). VR group showed greater level of improvement pre- and post-test.

Gasco et al. [22]

26 (all novices)

Place 2 pedicle screws

Didactic lecture on surgical technique for procedure

Place 2 pedicle screws in benchtop model

Screw placement, choice of screw, pedicle breaches

SS less errors in all outcomes for VR group (more than 50% reduction in placement error (p < 0.001))

Henn et al. [14]

17 (all novices)

Touch 11 targets in the shoulder

No additional training

Probe-specific points within shoulder on cadaver

GOALS score (time to complete, dexterity, depth perception, efficiency, respect for tissue)

SS reduction in time for VR group (p < 0.05), with SS improvement from baseline (p < 0.05). Improvement in GOALS score was greater than control, but not SS (p = 0.98)

Hooper et al. [28]

14 (all novices)

Perform 2 simulated THAs

No additional training

Perform THA on cadaver

THA score, GRS

VR group showed greater improvement from baseline in all outcomes; however, this was not SS (p = 0.078). Only technical performance was SS (p = 0.009)

Hou et al. [23]

10 (all novices)

Perform pedicle screw placement

Didactic lecture and video on surgical technique for procedure

Perform cervical pedicle screw placement on cadaver

Screw placement

SS higher ‘acceptable’ screw placement in VR group (100% vs 50% in control group, p = <0.05). SS higher ‘ideal’ screw placements for VR group (p = <0.05)

Lohre et al. [15]

26 (19 intermediates, 7 experts)

Complete module outlining key steps in glenoid exposure procedure

Read technical article outlining steps of procedure

Perform glenoid exposure on cadaver

Time to complete, OSATS, completion of procedure-specific checklist

SS reduction in time for VR group (p = 0.04). Improvement in OSATS score, however only SS improvement over control in instrument handling (p = 0.03)

Middleton et al. [21]

17 (all novices)

Visualisation, probing of anatomical structures within the knee

Visualisation, probing of anatomical structures within the knee on benchtop simulator

All groups perform visualisation and probing of anatomical structures within the knee on both benchtop and VR simulators

Motion analysis (total time taken and number of hand movements), GRS

Both groups improved from baseline (p = <0.05). Control group showed SS improvement on VR test (p = <0.05), but VR group did not show SS improvement on benchtop test (p= > 0.05). VR group did not consistently outperform control group on VR test.

Pahuta et al. [26]

48 (all novices)

Drawing of both column hemipelvis fracture lines

Control 1: draw fracture lines on benchtop model

Control 2: read article on fracture carving, view 3D CT images

Drawing of both column hemipelvis fracture lines on surgically arranged benchtop hemipelvis, in 5 min

Accuracy of drawn fracture lines against known anatomical features of both-column fractures

VR group performed SS better than both control groups (p = 0.0001, p = 0.0026); lines were more accurate and had correct spatial relationships. No SS difference between control groups.

Rebolledo et al. [16]

14 (all novices)

Probing of spheres on anatomical landmarks in the knee and shoulder

2 h of didactic lectures on surgical technique

Perform standard diagnostic arthroscopy on knee and shoulder cadaver model

Time to complete, generated injury grading index (dexterity, collisions, injury to tissue)

SS reduction in time (p = 0.02) and injury grading index (p = 0.01) for VR group in shoulder exercises. VR group performed better than control in knee exercises, but differences were not SS (p = 0.09, p = 0.08)

Sugand et al. [27]

52 (all intermediates)

Perform fixation of intertrochanteric fracture, 5x a week for 2 weeks

Perform fixation of intertrochanteric fracture, 1x a week for 2 weeks

Perform fixation of intertrochanteric fracture in VR

Time to complete, total fluoroscopy time, number of attempts to place guidewire, GRS

VR group performed better than control with SS in all outcomes (p = <0.001). VR also showed greater improvement from baseline than control.

Waterman et al. [17]

22 (all intermediates)

Location of spheres in anatomical locations in shoulder, palpation of spheres

No additional training

Perform shoulder arthroscopy on live patient

Time to complete, camera distance, probe distance, ASSET

VR group had SS improvement from baseline (p = 0.01). VR group was SS faster than control (p = 0.01). ASSET score and camera distance were better the VR group, however without SS (p = 0.061, p = 0.070).

Xin et al. [24]

16 (all intermediates)

Perform pedicle screw placement

Watch demonstration of correct nail placement and technique on 3D-printed model.

Placement of 6 pedicle screws T11-L4 on cadaver

Time for each screw, position of screw

SS higher ‘acceptable’ screw placement in VR group (100% vs 79.2% in control group, p = <0.05). SS higher ‘ideal’ screw placements for VR group (p = <0.05). SS reduction in time for VR group (p = <0.05).