Does Surgeon Experience Impact the Risk of Complications After Bernese Periacetabular Osteotomy?

Abstract

Background Bernese periacetabular osteotomy (PAO) is a technically challenging procedure with potential risk for major complications and a previously reported steep learning curve. However, the impact of contemporary hip preservation fellowships on the learning curve of PAO has not been established. Questions/purposes (1) What was the frequency of major complications during the PAO learning curve of two surgeons who recently graduated from hip preservation fellowships? (2) Is increasing level of experience associated with the risk of a complication and with operative time, a possible surrogate measure of surgical performance? Methods We retrospectively studied 81 PAOs performed by one of two surgeons who recently graduated from a hip preservation fellowship during their first 4 years of practice in two institutions. One of the surgeons participated as a fellow in 78 PAOs with an increasing level of responsibility during the course of 1 full year. The other surgeon performed 41 PAOs as a fellow during 6 months, also with an increasing level of responsibility during that time. There were 68 (84%) female and 13 (16%) male patients (mean age, 18 years; range, 10-36 years). The frequency of complications was recorded early and at 1 year after surgery and graded according to a validated classification system describing five grades of complications. Complications that required surgical intervention (Grade III) and life-threatening complications (Grade IV) were considered major complications. Persistent pain after surgery, although considered a failure of PAO, was not considered a surgical complication as a result of the multifactorial etiology of pain after hip-preserving surgery. However, early reoperation and revision surgery were counted as complications. To evaluate the association between increasing level of experience and the occurrence of complications, we divided each surgeon's experience into his first 20 procedures (initial interval) and his second 20 (experienced interval) to test whether the incidence of complications or operative time was different between the two intervals. Because the association between experience and the likelihood of a complication was estimated to be consistent between the two surgeons, the analysis was performed with data pooled from the two surgeons. To test whether there was a difference in the likelihood of a complication in the Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research 1 editors and board members are on file with the publication and can be viewed on request. Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical princ...

Structured-mentorship Program for Periacetabular Osteotomy Resulted in Few Complications for a Low-volume Pelvic Surgeon

“…Of the PAOs performed during the learning phase of the mentorship program (first 26 PAOs), none had a Sink Grade III or IV complication at 12 months. Similar to Novais et al [34], our study suggests that the risk of a Grade III or IV complication did not decrease with increasing surgeon experience. The reoperation rate beyond the 12-month postoperative period was not dissimilar to many other published series [11,49].…”

“…The best method of training a surgeon to perform this complex procedure is yet to be determined. Although distant mentorship may be a potential method of learning PAO, Novais et al [34] have shown that two young surgeons initially trained within a formal structured hip preservation fellowship can perform PAO with a relatively low risk of complications. However, after this initial period, surgeons in a geographically isolated region are likely to perform PAO infrequently.…”

“…Moreover, our outcomes cannot be comprehensively or directly compared with other centers because there are many other factors beyond clinical, radiologic, and survivorship outcomes that can and have been used to evaluate outcomes of PAO. In addition, we have not presented surgical-time data, which have been considered to be a possible surrogate measure for surgical performance and learning curve [34]. However, surgical time is likely to be an outcome affected by multiple factors such as complexity of the procedure and the experience of the entire surgical team.…”

“…The bone between the ilium osteotomy and posterior column, along the ilioischial line, is often very sclerotic and of variable thickness and orientation, rendering it prone to fracture. Although these complications are still reported, it is likely that many fractures are not initially recognized or reported but subsequently identified on three-dimensional imaging [34]. This may contribute to the reported prevalence of pubic nonunions (5%-14%) and pubic stress fractures (2%-18%) [27,42].…”

CORR Insights®: Operative Fluoroscopic Correction Is Reliable and Correlates With Postoperative Radiographic Correction in Periacetabular Osteotomy

“…Proper acetabular reorientation can improve long-term survivorship and decelerate the progression of degenerative changes [1]. Overcorrection can produce femoroacetabular impingement, undercorrection may leave a patient with persistent symptoms, and poor congruency of the joint can cause abnormal contact stresses and accelerated chondral damage [4,9]. Thorough preoperative planning is fundamental in PAO, and is based on plain radiographs and, more importantly, on CT imaging [6].…”