The association between surgeon grade and risk of revision following total hip arthroplasty

Abstract

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.

Consultant revision hip arthroplasty volumes and new consultant volume trajectories in England, Wales, Northern Ireland, and the Isle of Man

“…Volume calculations will not capture relevant surgical experience acquired by consultants prior to the start of their NJR records, such as skills acquired during surgical training and specialist fellowships. 12 We acknowledge that the responsible consultant may not always be the lead (operating) consultant, but in 90% of cases it was. We focused our analyses on reporting trailing annual volumes of HA, however any future work relating volumes to outcome must also explore longer time windows for measuring volume, in addition to considering the impact of cumulative volumes for PHA and RHA along with combined primary and revision volume.…”

75 years young

“…It is always reassuring to read reflections from those heavily involved in the analysis of registry data about its advantages, disadvantages, value moving forward, and in particular, how it could be improved. [8][9][10][11][12][13][14][15][16][17][18][19][20] We also broach optimal management in acute trauma with an excellent annotation from Vallier, 21 which will hopefully give insight and stimulate debate.…”

Important matters that need attention

“…We need a diverse surgical profession, we must facilitate training for all, and we need to ensure that every trainee surgeon finishes their training with the competencies that are needed to deliver excellent independent care. [10][11][12][13][14][15][16] In this issue we also have a number of papers on hip preservation. [17][18][19][20] This is a topic of great importance where our understanding and recognition of the pathology, and our interventions, have improved dramatically over the last 30 years.…”

“…We need a diverse surgical profession, we must facilitate training for all, and we need to ensure that every trainee surgeon finishes their training with the competencies that are needed to deliver excellent independent care. 10-16…”