Significant learning curve found for revision TJA among inexperienced surgeons
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Key takeaways:
- Revision total joint arthroplasty was linked with a significant learning curve for inexperienced surgeons.
- Inexperienced surgeons had longer surgeries and patients with more blood loss and early reoperations.
According to published results, revision total joint arthroplasty performed by surgeons with less experience may result in longer surgeries, increased blood loss and early reoperations compared with surgeons with more experience.
Kent R. Kraus, MD, resident appointee in the department of orthopedic surgery at Indiana University School of Medicine, and colleagues analyzed prospectively collected data from 122 aseptic revision total hip arthroplasties and 195 aseptic revision total knee arthroplasties performed between July 2019 and October 2022.
Kraus and colleagues compared procedure duration, patients’ estimated blood loss and reoperation rates between four surgeons of varying experience levels, which were based on years in practice. Surgeries were performed by two inexperienced surgeons (0 to 2 years of practice), one surgeon with early experience (4 to 6 years of practice) and one surgeon with senior experience (15 to 17 years of practice).
Among revision THAs, procedure duration was 92 minutes for the senior surgeon, 108.8 minutes for the surgeon with early experience and 164.3 minutes for the inexperienced surgeons. Similarly, among revision TKAs, procedure duration was 95 minutes for the senior surgeon, 135.1 minutes for the surgeon with early experience and 216.8 minutes for the inexperienced surgeons. Kraus and colleagues noted procedure duration also varied based on reason for revision, patient age and BMI.
Kraus and colleagues found no differences in estimated blood loss for all levels of surgeon experiences among revision THAs. However, among revision TKAs, the inexperienced surgeons had the most estimated blood loss (6.01 g/dL), followed by the surgeon with early experience (5.96 g/dL) and the senior surgeon (5.41 g/dL).
In addition, the inexperienced surgeons had the highest 1-year reoperation rates for revision THAs (25%), followed by the surgeon with early experience (15.5%) and the senior surgeon (3.6%).
“Our findings emphasize the importance of senior colleagues sharing their experience and techniques with their junior colleagues,” Kraus and colleagues wrote in the study. “Study findings suggest that emphasis should be placed on safely reducing procedure duration for revision TJA. This may decrease blood loss and the need for blood transfusions.”
Perspective
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In the excellent study by Kent R. Kraus, MD, and colleagues, they reviewed revision total hip and knee procedures and compared outcomes based on surgeon experience at an academic institution. They demonstrated that while BMI and case complexity are major factors, senior surgeons have shorter operative times as well as less blood loss and reoperations for their patients. This single institution study highlights important facets regarding how surgeon experience can affect patient outcomes. It exemplifies a familiar phrase many surgeons have heard in training: “Speed should be the daughter of experience and not the mother of chaos.”
As Kraus and colleagues mentioned, it is common for the least experienced surgeons to tackle the most complex cases. Revision arthroplasty has more risk, takes more time, planning and resources, and does not reimburse as well as primary arthroplasty. Newer surgeons are often willing to take challenging cases trying to build a practice, while more senior surgeons may not need to take on the challenging cases in their practice. By not appropriately reimbursing for the added time and energy expenditure, the current relative value unit system may be funneling patients who need a revision arthroplasty into the least experienced hands, which may affect patient outcome. This may also reduce patient care options as more revision cases are being funneled from the community to academic centers.
References:
Haug EC, et al. J Arthroplasty. 2021;doi:10.1016/j.arth.2021.02.034.
Illgen RL, et al. J Arthroplasty. 2021;doi:10.1016/j.arth.2020.10.030.
Patel A, et al. J Arthroplasty. 2022;doi:10.1016/j.arth.2022.03.025.
Patterson DC, et al. J Arthroplasty. 2017;doi:10.1016/j.arth.2017.04.044.
Quan T, et al. J Arthroplasty. 2021;doi:10.1016/j.arth.2020.11.034.
Sodhi N, et al. J Arthroplasty. 2018;doi:10.1016/j.arth.2017.09.019.
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