RESUMEN
BACKGROUND: Unicompartmental knee replacements (UKRs) are performed by surgeons at various stages in training with varying levels of supervision, but we do not know if this is a safe practice with comparable outcomes to consultant-performed UKR. The aim of this study was to use registry data for England and Wales to investigate the association between surgeon grade (consultant, or trainee), the senior supervision of trainees (supervised by a scrubbed consultant, or not), and the risk of revision surgery following UKR. METHODS AND FINDINGS: We conducted an observational study using prospectively collected data from the National Joint Registry for England and Wales (NJR). We included adult patients who underwent primary UKR for osteoarthritis (n = 106,206), recorded in the NJR between 2003 and 2019. Exposures were the grade of the operating surgeon (consultant, or trainee) and whether or not trainees were directly supervised by a consultant during the procedure (referred to as "supervised by a scrubbed consultant"). The primary outcome was all-cause revision surgery. The secondary outcome was the number of procedures revised for the following specific indications: aseptic loosening/lysis, infection, progression of osteoarthritis, unexplained pain, and instability. Flexible parametric survival models were adjusted for patient, operation, and healthcare setting factors. We included 106,206 UKRs in 91,626 patients, of which 4,382 (4.1%) procedures were performed by a trainee. The unadjusted cumulative probability of failure at 15 years was 17.13% (95% CI [16.44, 17.85]) for consultants, 16.42% (95% CI [14.09, 19.08]) for trainees overall, 15.98% (95% CI [13.36, 19.07]) for trainees supervised by a scrubbed consultant, and 17.32% (95% CI [13.24, 22.50]) for trainees not supervised by a scrubbed consultant. There was no association between surgeon grade and all-cause revision in either crude or adjusted models (adjusted HR = 1.01, 95% CI [0.90, 1.13]; p = 0.88). Trainees achieved comparable all-cause survival to consultants, regardless of the level of scrubbed consultant supervision (supervised: adjusted HR = 0.99, 95% CI [0.87, 1.14]; p = 0.94; unsupervised: adjusted HR = 1.03, 95% CI [0.87, 1.22]; p = 0.74). Limitations of this study relate to its observational design and include: the potential for nonrandom allocation of cases by consultants to trainees; residual confounding; and the use of the binary variable "surgeon grade," which does not capture variations in the level of experience between trainees. CONCLUSIONS: This nationwide study of UKRs with over 16 years' follow up demonstrates that trainees within the current training system in England and Wales achieve comparable all-cause implant survival to consultants. These findings support the current methods by which surgeons in England and Wales are trained to perform UKR.
Asunto(s)
Artroplastia de Reemplazo de Rodilla , Sistema de Registros , Reoperación , Humanos , Reoperación/estadística & datos numéricos , Artroplastia de Reemplazo de Rodilla/educación , Artroplastia de Reemplazo de Rodilla/efectos adversos , Artroplastia de Reemplazo de Rodilla/métodos , Masculino , Femenino , Anciano , Persona de Mediana Edad , Gales , Inglaterra , Cirujanos/educación , Competencia Clínica , Factores de Riesgo , Osteoartritis de la Rodilla/cirugía , Resultado del TratamientoRESUMEN
AIMS: Total hip arthroplasties (THAs) are performed by surgeons at various stages in training with varying levels of supervision, but we do not know if this is safe practice with comparable outcomes to consultant-performed THA. Our aim was to examine the association between surgeon grade, the senior supervision of trainees, and the risk of revision following THA. METHODS: We performed an observational study using National Joint Registry (NJR) data. We included adult patients who underwent primary THA for osteoarthritis, recorded in the NJR between 2003 and 2016. Exposures were operating surgeon grade (consultant or trainee) and whether or not trainees were directly supervised by a scrubbed consultant. Outcomes were all-cause revision and the indication for revision up to ten years. We used methods of survival analysis, adjusted for patient, operation, and healthcare setting factors. RESULTS: We included 603,474 THAs, of which 58,137 (9.6%) procedures were performed by a trainee. There was no association between surgeon grade and all-cause revision up to ten years (crude hazard ratio (HR) 1.00 (95% confidence interval (CI) 0.94 to 1.07); p = 0.966), a finding which persisted with adjusted analysis. Fully adjusted analysis demonstrated an association between trainees operating without scrubbed consultant supervision and an increased risk of all-cause revision (HR 1.10 (95% CI 1.00 to 1.21); p = 0.045). There was an association between trainee-performed THA and revision for instability (HR 1.14 (95% CI 1.01 to 1.30); p = 0.039). However, this was not observed in adjusted models, or when trainees were supervised by a scrubbed consultant. CONCLUSION: Within the current training system in England and Wales, appropriately supervised trainees achieve comparable THA survival to consultants. Trainees who are supervised by a scrubbed consultant achieve superior outcomes compared to trainees who are not supervised by a scrubbed consultant, particularly in terms of revision for instability. Cite this article: Bone Joint J 2022;104-B(3):341-351.
Asunto(s)
Artroplastia de Reemplazo de Cadera/normas , Competencia Clínica , Reoperación/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Sistema de Registros , Medición de RiesgoRESUMEN
OBJECTIVE: To investigate the association between surgeon grade (trainee vs consultant) and implant survival following primary hip and knee replacement. DESIGN: A systematic review and meta-analysis of observational studies. DATA SOURCES: MEDLINE and Embase from inception to 6 October 2021. SETTING: Units performing primary hip and/or knee replacements since 1990. PARTICIPANTS: Adult patients undergoing either a primary hip or knee replacement, predominantly for osteoarthritis. INTERVENTION: Whether the surgeon recorded as performing the procedure was a trainee or not. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was net implant survival reported as a Kaplan-Meier survival estimate. The secondary outcome was crude revision rate. Both outcomes were reported according to surgeon grade. RESULTS: Nine cohort studies capturing 4066 total hip replacements (THRs), 936 total knee replacements (TKRs) and 1357 unicompartmental knee replacements (UKRs) were included (5 THR studies, 2 TKR studies and 2 UKR studies). The pooled net implant survival estimates for THRs at 5 years were 97.9% (95% CI 96.6% to 99.2%) for trainees and 98.1% (95% CI 97.1% to 99.2%) for consultants. The relative risk of revision of THRs at 5 and 10 years was 0.88 (95% CI 0.46 to 1.70) and 0.68 (95% CI 0.37 to 1.26), respectively. For TKRs, the net implant survival estimates at 10 years were 96.2% (95% CI 94.0% to 98.4%) for trainees and 95.1% (95% CI 93.0% to 97.2%) for consultants. We report a narrative summary of UKR outcomes. CONCLUSIONS: There is no strong evidence in the existing literature that trainee surgeons have worse outcomes compared with consultants, in terms of the net survival or crude revision rate of hip and knee replacements at 5-10 years follow-up. These findings are limited by the quality of the existing published data and are applicable to countries with established orthopaedic training programmes. PROSPERO REGISTRATION NUMBER: CRD42019150494.