Bridging the gap: A scoping review of wet and dry lab simulation training in orthopaedic surgical education

Abstract

BACKGROUND

Orthopaedic surgical education has traditionally depended on the apprenticeship model of “see one, do one, teach one”. However, reduced operative exposure, stricter work-hour regulations, medicolegal constraints, and patient safety concerns have constrained its practicality. Simulation-based training has become a reliable, safe, and cost-efficient alternative. Dry lab techniques, especially virtual and augmented reality, make up 78% of current dry lab research, whereas wet labs still set the standard for anatomical realism.

AIM

To evaluate the effectiveness, limitations, and future directions of wet and dry lab simulation in orthopaedic training.

METHODS

A scoping review was carried out across four databases-PubMed, Cochrane Library, Web of Science, and EBSCOhost-up to 2025. Medical Subject Headings included: "Orthopaedic Education", "Wet Lab", "Dry Lab", "Simulation Training", "Virtual Reality", and "Surgical Procedure". Eligible studies focused on orthopaedic or spinal surgical education, employed wet or dry lab techniques, and assessed training effectiveness. Exclusion criteria consisted of non-English publications, abstracts only, non-orthopaedic research, and studies unrelated to simulation. Two reviewers independently screened titles, abstracts, and full texts, resolving discrepancies with a third reviewer.

RESULTS

From 1851 records, 101 studies met inclusion: 78 on dry labs, 7 on wet labs, 4 on both. Virtual reality (VR) simulations were most common, with AI increasingly used for feedback and assessment. Cadaveric training remains the gold standard for accuracy and tactile feedback, while dry labs-especially VR-offer scalability, lower cost (40%-60% savings in five studies), and accessibility for novices. Senior residents prefer wet labs for complex tasks; juniors favour dry labs for basics. Challenges include limited transferability data, lack of standard outcome metrics, and ethical concerns about cadaver use and AI assessment.

CONCLUSION

Wet and dry labs each have unique strengths in orthopaedic training. A hybrid approach combining both, supported by standardised assessments and outcome studies, is most effective. Future efforts should aim for uniform reporting, integrating new technologies, and policy support for hybrid curricula to enhance skills and patient care.

Key Words: Orthopaedic education; Wet lab; Dry lab; Simulation training; Virtual reality; Surgical procedure

Core Tip: Orthopaedic training faces challenges like less operative exposure, safety concerns, and limited hours. Simulation-based education provides safe, consistent skill development. This review compares wet and dry labs, with virtual reality leading in dry labs (78%), and cadavers still the most realistic. Each method has advantages, and a hybrid approach can connect basic and advanced training. Standardized metrics and policies are key for adopting hybrid curricula.

INTRODUCTION

Orthopaedic trainees today perform 30%-40% fewer surgical procedures during their residency compared to those from twenty years ago[1]. This is mainly due to shorter working hours, higher litigation risks, and a greater focus on patient safety. Traditionally, orthopaedic training has relied on an apprenticeship model, where trainees acquire skills under the guidance of experienced mentors in real surgical environments. The apprenticeship model encapsulated by the phrase "see one, do one, teach one" has been a cornerstone of surgical training for over a century, producing generations of skilled surgeons.

However, this model is increasingly regarded as inadequate in modern surgical education due to several reasons. The rapid expansion of medical knowledge, the focus on patient safety, and the development of new technologies have driven a shift towards a competency-based training approach that prioritises the quality of skills over the number of procedures carried out[2-4]. In addition, this traditional method may leave trainees without experience in specific procedures or diverse patient management scenarios. This is because the model relies on the cases available during training, which may not encompass all essential aspects.

The main driving force behind this change is patient safety concerns; the traditional model, which often involved hands-on learning with patients, is viewed as less suitable in modern practice[5]. Allowing inexperienced surgeons to operate, even under supervision, raises concerns about patient safety, legal implications, and healthcare costs. Inexperienced surgeons are prone to technical errors, leading to severe outcomes like permanent disability or death[6]. Furthermore, the constraints of modern healthcare systems, characterised by reduced working hours and the substantial expenses associated with operating room utilisation, have progressively hindered the feasibility of the conventional apprenticeship model[4].

Implementing simulation technologies like high-fidelity human patient simulations and three-dimensional printing offers alternative skill acquisition methods that reduce patient risks and allow repeated practice in a controlled setting[7]. Simulation-based education provides structured, reproducible, risk-free surgical training environments, aligning with patient-centered care by enabling surgeons to gain competence without risking patient safety[8]. It encompasses a variety of modalities, including cadaver models, synthetic bones, and advanced virtual reality (VR) systems, thereby enabling the practice of complex procedures and minimally invasive techniques[9].

Simulation training is broadly classified into two primary categories: Dry lab and wet lab methods. Dry lab includes synthetic models and VR simulators, which are effective in the early stages of the learning curve, allowing trainees to develop foundational skills without the risk of patient harm[10,11]. VR simulators, integrated with haptic technology, provide high-fidelity training experiences that can emulate real-life scenarios, such as intraoperative haemorrhaging, thereby augmenting the realism and efficacy of the training[12]. On the other hand, Wet lab methods involve the utilization of cadaveric or animal specimens, which are regarded as high-fidelity models that provide realistic anatomical and tactile feedback, essential for advanced surgical training[10-13].

Despite its growing application, a lack of consensus persists regarding the most effective simulation modality, particularly within orthopaedic surgery. This review aims to evaluate the effectiveness of both dry and wet lab training, comparing and contrasting their respective strengths and weaknesses. Additionally, we seek to assess the status of orthopaedic simulation training, identifying gaps in the literature and potential areas for future research.

MATERIALS AND METHODS

This study was conducted as a scoping review following PRISMA-ScR guidelines. A scoping review was selected over systematic review or meta-analysis due to heterogeneity in study designs, simulation methods, and outcomes, which prevented quantitative synthesis.

A comprehensive literature search was conducted in PubMed, Cochrane Library, Web of Science, and EBSCOhost from the inception of each database until January 2025. The search strategy integrated Medical Subject Headings and free-text terms, including: “Orthopaedic Education”, “Wet Lab”, “Dry Lab”, “Simulation Training”, “Virtual Reality”, and “Surgical Procedure”. Boolean operators (AND/OR) and database-specific filters for human studies and publications in English were employed. Additionally, reference lists of all eligible articles and pertinent reviews were manually examined to identify supplementary studies.

Studies were eligible if they focused on orthopaedic or spinal surgical education, using wet lab (cadaveric or animal tissue) or dry lab (synthetic models, virtual/augmented reality, or computer-assisted simulation) training methods to evaluate the effectiveness, feasibility, or educational outcomes of simulation training. Exclusion criteria included studies unrelated to orthopaedic surgery, conference abstracts, editorials, commentaries, non-peer-reviewed sources, or articles not available in English.

All records imported into EndNote X9 for duplicates. Two reviewers independently screened titles and abstracts against criteria. Relevant articles' full texts were then assessed. Discrepancies were resolved via discussion or by a third reviewer if needed. Figure 1 illustrated the screening process and selection of studies, adapted from the PRISMA guidelines.

Figure 1  PRISMA flow chart.

RESULTS

The initial search found 1851 records. After removing duplicates and screening titles and abstracts, 295 articles were assessed, with 101 meeting inclusion criteria for wet or dry lab orthopaedic or spinal surgery training. Among these, 78 studied dry labs, 7 focused on wet labs, and four directly compared both[14-20].

Dry lab approaches made up 77% of studies, mainly including: VR simulators (52) for arthroscopy, arthroplasty, trauma fixation; AR systems (10) for fracture fixation and spatial tasks; synthetic bone/joint models (9) for fracture fixation and arthroplasty; and computer-assisted or 3D-printed models (7) for rehearsal. VR platforms enhance skills, cut task times, and boost confidence[21-29]. Low-fidelity models benefit novices by enabling safe repetition of basic procedures[23]. A notable trend was incorporating AI into VR simulators, as reported in several studies[18,26].

Only seven studies focused on wet labs, most of which involved cadaveric training[14,15,19]. Cadaver-based models are the gold standard for surgical training because of their realism, anatomical variability, and tactile feedback. They are especially valued for complex procedures like diagnostic knee arthroscopy, anterior cruciate ligament (ACL) reconstruction, and arthroplasty[14,15,19].

Animal tissue models (e.g., goat eyes, porcine knees) were used for arthroscopy or osteotomy training but faced limitations due to logistics, cost, and ethical concerns[25].

Only four studies directly compared wet and dry lab training[14,16,19,20]. A consistent pattern emerged: Dry labs were most effective for junior trainees, providing a safe environment for practising basic skills and reducing anxiety[20,22]. Senior residents and fellows preferred wet labs, valuing their accuracy for complex, high-stakes procedures[22,28]. These findings support a hybrid model where trainees move from VR to cadavers before live surgery[14,19].

DISCUSSION

The incorporation of simulation-based education into orthopaedic training has gained attention in recent years. Wet labs typically refer to settings that use cadavers, animal tissue, or synthetic models with realistic tissue characteristics. These labs provide hands-on experience with surgical instruments and implants, allowing trainees to practise procedures in environments that mimic real-life scenarios. These labs are often employed for intricate procedures, including arthroscopies and osteotomies, where tactile feedback and anatomical accuracy are critical[14-16]. Conversely, dry labs utilise synthetic models, VR, or computer-assisted systems to simulate surgical procedures. These models are specifically designed to replicate the technical aspects of surgeries without necessitating biological tissue. Dry labs offer cost-effective, reusable, and accessible options, ideal for practice and skill enhancement. They are commonly used in arthroscopy, knee replacement surgery, and trauma surgery training[17,18].

Effectiveness of wet and dry labs

Wet labs are highly valued for their authenticity. Cadaveric training enhances technical skills and boosts confidence when performing surgical procedures. These facilities enable trainees to practice complex procedures in a realistic environment, including arthroscopic rotator cuff repair and anterior cruciate ligament reconstruction. A study on cadaveric training for diagnostic knee arthroscopy found that participants who trained with cadaveric models reached proficiency more quickly than those who did not[14]. As a result, it minimises errors in practical surgical situations while upholding high-quality standards in orthopaedic education[19].

Dry labs, particularly those integrating VR, have emerged as cost-effective alternatives to wet laboratories. These tools benefit novice surgeons by offering a safe space to practice and refine basic surgical skills, including instrument handling and procedural steps, before progressing to tackling more complex tasks[17,20,21]. VR simulators are shown to improve arthroscopic skills, decrease anxiety, and boost confidence[21,22]. A study on low-fidelity arthroscopic simulators demonstrated reduced task completion time and enhanced technical performance among novice surgeons[23].

Practical application of wet and dry labs

As previously stated, wet labs shine in advanced surgical training, mainly where the intricacies of human anatomy and tissue handling are paramount. This is exemplified in procedures such as the ACL[24]. Wet labs provide opportunities for trainees to practice rare or high-stakes procedures, which may not be feasible in real-world settings, mainly due to patient safety[25]. Dry labs are widely used to develop foundational skills and serve as a precursor to cadaveric training, making them particularly suitable for large-scale implementation in residency programs. This is further enhanced by the implementation of VR platforms as immersive and interactive experiences for real-world surgical scenarios, such as diagnostic arthroscopy skills[14,26,27].

Cost and accessibility

Wet labs frequently incur expenses and pose logistical challenges in the organisation due to the costs associated with cadavers, animal tissues, and disposable instruments. These limitations can impede accessibility, particularly in resource-constrained environments[16]. Conversely, dry laboratories are more cost-effective and accessible, reducing training costs by 40%-60% compared with cadaveric training. This quality renders them ideal for institutions with limited resources[17,18]. Institutions with limited resources may favour dry labs, reserving cadaveric training for regional centres or advanced fellowships, as summarised in Table 1.

Table 1 Comparison of wet and dry labs in orthopaedic surgery training.

Aspect	Wet lab	Dry lab	Ideal learner stage
Tissue/model type	Human cadavers, animal tissue, or high-fidelity synthetic specimens	Synthetic bone models, computer-assisted simulators, virtual/augmented reality	Junior trainees (dry lab) progressing to senior trainees (wet lab)
Cost	High-cadaver procurement, animal tissue, single-use instruments, facilities	Lower-reusable synthetic models and scalable VR platforms	Dry labs ideal for early exposure in resource-limited settings
Tactile feedback	Excellent-realistic anatomical variation and soft tissue fidelity	Limited, though improving with haptics and force-feedback systems	Wet labs best for refining advanced skills requiring force precision
Accessibility	Restricted by cadaver availability, regulations, and infrastructure	Widely accessible, portable, and scalable across institutions	Dry labs suitable for frequent, repetitive practice early in training
Skill transfer	High-closely mirrors real surgical conditions and operating room workflow	Moderate-strong for basic/intermediate tasks; uncertain for complex skills	Dry labs build foundations; wet labs consolidate advanced readiness
Learner preference	Favoured by senior residents and fellows for complex, high-stakes procedures	Favoured by medical students and junior residents for early skill acquisition	Hybrid model aligns with progression from novice to advanced learner

VR: Virtual reality.

Learner preference and engagement

Many senior residents prefer wet labs due to their hands-on experience with actual instruments and implants, which is invaluable for refining advanced surgical skills[22,28]. Conversely, junior residents tend to favour dry labs, particularly those utilising VR simulators, as they offer a stress-free environment conducive to learning fundamental skills without the pressure associated with working on actual tissue[20,22]. Furthermore, dry labs are regarded as a beneficial complement to traditional training methods, with a significant majority of residents indicating a desire for increased simulation-based training[22].

Skill transfer to real-life surgery

The competencies developed in wet labs are effectively transferable to real-life surgical scenarios, as the realistic nature of the training closely parallels actual operating room conditions[14,16]. Although dry labs effectively impart basic skills, there exists a degree of debate regarding the transferability of these skills to actual surgical practice. Nevertheless, studies have demonstrated that VR simulators can enhance performance in cadaveric models, indicating that dry labs can be a valuable intermediate step in the educational process[20,29]. Future research should focus on developing validated, competency-based outcome measures. Table 1 presents the comparison between wet and dry Labs utilized in orthopaedic surgery training.

Regional education systems and simulation-based training

In Europe, numerous regional initiatives have been established to integrate simulation-based training into orthopaedic curricula. For example, in Northern Ireland, simulation sessions such as pelvic trauma scenarios and arthroscopy courses have been incorporated into the curriculum. Consequently, these sessions have received positive feedback, with trainees reporting enhanced confidence in managing complex cases[30]. Similarly, in France, although simulation-based training has not been fully implemented, educators and residents acknowledge its potential advantages[31]. In Italy, cadaveric labs are highly esteemed for their educational significance, as trainees indicate an enhanced comprehension of surgical anatomy and technique[32].

In the United States, residency programs have embraced hybrid models that integrate wet and dry lab training. For example, the Orthopaedic education program at Oregon Health and Science University has established a high-fidelity training curriculum designed to optimise the use of cadaveric specimens while simultaneously fostering partnerships with industry to mitigate costs[33]. Furthermore, research in the United States has underscored the efficacy of VR simulators in enhancing arthroscopic skills, notably indicating that junior residents experience significant advantages from this method[22]. In a similar vein, various regions have demonstrated that integrating virtual and realistic anatomical models significantly enhances surgical training by providing a safer environment conducive to skill development. Regional collaboration and the sharing of best practices can help standardise simulation-based training worldwide.

Limitations of each method

Orthopaedic training encompasses dry and wet lab methodologies, each with unique limitations. Dry lab models often fail to replicate the complexities of real-world clinical scenarios, potentially leading to a false sense of proficiency among learners[34]. Moreover, simulation training may not sufficiently equip students for the variability and unpredictability inherent in clinical practice, including patient diversity and environmental stressors[34]. It lacks the tactile feedback and anatomical complexity of wet labs, potentially limiting their effectiveness for advanced training[35]. Moreover, additional costs associated with acquiring and maintaining high-fidelity simulators in economically disadvantaged environments can impose a significant financial burden on educational institutions, limiting access and scalability[36].

Conversely, wet lab training encounters logistical obstacles, including the difficulty of accessing laboratories situated a considerable distance from clinical environments and the challenges associated with obtaining essential materials such as goat eyes, particularly given residents' demanding schedules[37]. They also suffer from inadequate infrastructure and substandard instruments, limiting their effectiveness[37]. The other concern regarding wet labs is that they are resource-intensive and may not be accessible to all training programs due to elevated costs and logistical challenges[31,32].

Using cadaveric tissue raises ethical issues that may conflict with the values of all trainees. Ethical considerations predominantly revolve around the respect for human dignity, informed consent, and the origin of cadavers[38]. Numerous nations have established stringent ethical frameworks concerning body donation, highlighting principles such as autonomy, altruism, and dignity, as delineated by the Human Tissue Authority in the United Kingdom and the Nuffield Council on Bioethics[38]. Nonetheless, utilising unclaimed bodies, frequently obtained from forensic mortuaries, raises ethical dilemmas, especially concerning consent and the dignity of the deceased[39,40]. On the other hand, Dry labs provide a controlled training environment that is free from the constraints of availability and the ethical concerns associated with the use of cadavers[8].

Future directions

The optimal approach to surgical training likely involves a combination of wet and dry laboratories, as both provide unique advantages that complement each other in the development of comprehensive surgical skills. The integration of wet and dry lab training is imperative to address the challenges presented by diminished hands-on experience resulting from work-hour restrictions and the need for a cost-effective training solution[41,42]. For instance, novice surgeons may find it beneficial to undergo initial training on low-fidelity simulators to cultivate fundamental arthroscopic skills, subsequently progressing to cadaveric training to refine their techniques[14]. This hybrid model guarantees that trainees attain both foundational and advanced surgical skills progressively and cost-effectively, thereby ensuring that orthopaedic trainees are adequately prepared to meet the demands of contemporary surgical practice[41,43].

VR is positioned to assume a pivotal role in the future of orthopaedic education. Its capacity to deliver immersive and interactive training experiences, in conjunction with objective performance metrics, renders it an indispensable resource for novice and experienced surgeons[26,27]. VR simulators can be integrated into current curricula, offering a flexible and scalable solution for surgical education and training.

Regional collaboration and the standardisation of training protocols are paramount to optimising the efficacy of simulation-based training. Regional Collaboration can help mitigate disparities in training opportunities, as simulation closes the gaps in procedural exposure among various regions[44].

Future research should conduct longitudinal studies on skill transfer and patient outcomes, develop standardised outcome metrics for surgical education, explore regional collaborations to share cadaveric resources and optimise curricula, and address ethical issues in cadaveric and artificial intelligence-based training.

CONCLUSION

This review underscores the significance of simulation-based training in orthopaedic surgery. Wet and dry laboratories each present distinct advantages within orthopaedic education, and their incorporation into surgical training curricula possesses the potential to enhance skill acquisition, improve patient outcomes, and mitigate the risks associated with traditional apprenticeship-based learning. Although wet laboratories offer realism and tactile feedback, dry laboratories provide cost-effectiveness and repeatability. The optimal training model combines both modalities, capitalising on their respective strengths to establish a comprehensive and effective educational experience. Future research should focus on integrating and evaluating these methods in tandem.