Introduction Current orthopaedic trainees are given less time to achieve competency in increasingly complex and diverse surgical procedures compared to their predecessors [1, 2] . The multitude of different surgical techniques that have emerged require volumes of supervised repetition to achieve competence. It can be considered that surgical competence for orthopaedic residents cannot be achieved solely by caseload alone in the time it takes to complete residency [3, 4] . Multiple factors,

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... mental to the goal of rigorous training can be identified, including resident work hour restrictions, increasing administrative duties and documentation, inconsistent case volumes, and other service related duties [5] . These challenges have been compounded with changes in healthcare policies that center on Operating Room (OR) efficiency, reaching quality assurance targets, patient safety, and reducing patient waiting times. Such issues have forced a dramatic deviation from the traditional paradigm of the teacher-apprentice model of professional training, previously followed for the last hundred years [6] . These evolving challenges have necessitated alternative strategies of skill acquisition, notably physical and virtual simulation, psychomotor training, cognitive training, and competency-based evaluation. Abstract Background: Orthopaedic surgical techniques are complex, rapidly evolving, and require significant training to attain competence. Hindrances to acquiring these complex skills during residency include: work hour restrictions, inconsistent case volumes, and policy changes centered on operating room (OR) efficiency and patient safety. The evolution of orthopaedic training in response to these challenges forced the development of non-patient-based training methods outside of the OR. Understanding how orthopaedic residents develop and retain surgical skills will hopefully provide more efficient training. The different methods, their respective advantages, and evidence of their efficacy is necessary to direct resident training in the future. Methods: PubMed and Google Scholar were searched for literature related to orthopaedic resident training. The resulting articles were used to find other manuscripts pertinent to the subject. Training methods involving patients were excluded. Results: Non-patient-based methods for orthopaedic resident surgical training include cognitive training for knowledge acquisition, low fidelity models for basic skills, bench-top models for arthroscopic skill development, cadaveric and animal models, synthetic bone models, and virtual reality simulators. Evidence for the type of training resulting in the most robust skills acquisition and retention, supports targeted, deliberate practice in spaced repetitions using a competency-based curriculum. Conclusion: A variety of non-patient based methods exist for surgical skill development, aimed at mitigating challenges faced by orthopaedic residents. Despite their abundance, evidence supporting direct transfer of skills learned via these methods to the OR is rare in orthopedics. Barriers to their use and implementation, namely a lack of funding, are prevalent.