Wednesday, May 1, 2013

Surgeon experience, case volume, what difference do they make in outcome?

Center and surgeon volume influence the revision rate following unicondylar knee replacement: an analysis of 23,400 medial cemented unicondylar knee replacements

The effects of the learning curve and surgical experience on the rate of revision surgery is of extreme interest in a technical field like orthopaedics. If we skip to the bottom line of this article, we see that the authors suggest that the surgical workload for an orthopaedic procedure (in this case a unicondylar knee replacement, but it could be any other) be concentrated in centers and with surgeons, allowing them to accumulate the necessary volumes required to improve patient outcomes.

So here's the study. The authors analyzed 23,400 medial cemented Oxford unicondylar knee replacements for the treatment of osteoarthritis. Total center and surgeon operative volumes were calculated over an eight-year time span since the inception of the registry (April 2003 to December 2010). The revision rate was calculated according to center volume and surgeon volume.

A total of 919 surgeons and a total of 366 centers performed at least one replacement, with the majority performing a small number of procedures. The revision rate for the surgeons with the lowest volume (twenty-five or fewer procedures), 2.16 revisions per 100 component years, was significantly higher than that for the surgeons with the highest volume (more than 200 procedures), 0.80 revisions per 100 component years. The five-year survival rate of 90.1% for the lowest-volume surgeons was also significantly lower than the rate of 96.0% for the highest-volume surgeons. Stating this in the other way, the five year failure rate for low volume surgeons is 10%  in contrast to 4% per year for highest volume surgeons - less than half.

While the authors suggest a threshold level, their data indicates that the benefit of experience continues to increase with increasing volume:

In any event, their evidence indicates that high-volume centers and surgeons specializing in such procedures had superior results compared with their low-volume counterparts.

The mechanisms by which experience exerts its effect are probably multiple, including optimizing patient selection, surgical technique, surgical teamwork and rehabilitation.  What is clear is that a >50% reduction in failure rate is something  to consider.

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