The role of surgeon volume on patient outcome in total knee arthroplasty: a systematic review of the literature

Abstract

BackgroundA number of factors have been identified as influencing total knee arthroplasty outcomes, including patient factors such as gender and medical comorbidity, technical factors such as alignment of the prosthesis, and provider factors such as hospital and surgeon procedure volumes. Recently, strategies aimed at optimizing provider factors have been proposed, including regionalization of total joint arthroplasty to higher volume centers, and adoption of volume standards. To contribute to the discussions concerning the optimization of provider factors and proposals to regionalize total knee arthroplasty practices, we undertook a systematic review to investigate the association between surgeon volume and primary total knee arthroplasty outcomes.MethodsWe performed a systematic review examining the association between surgeon volume and primary knee arthroplasty outcomes. To be included in the review, the study population had to include patients undergoing primary total knee arthroplasty. Studies had to report on the association between surgeon volume and primary total knee arthroplasty outcomes, including perioperative mortality and morbidity, patient-reported outcomes, or total knee arthroplasty implant survivorship. There were no restrictions placed on study design or language.ResultsStudies were variable in defining surgeon volume (‘low’: <3 to <52 total knee arthroplasty per year; ‘high’: >5 to >70 total knee arthroplasty per year). Mortality rate, survivorship and thromboembolic events were not found to be associated with surgeon volume. We found a significant association between low surgeon volume and higher rate of infection (0.26% - 2.8% higher), procedure time (165 min versus 135 min), longer length of stay (0.4 - 2.13 days longer), transfusion rate (13% versus 4%), and worse patient reported outcomes.ConclusionsFindings suggest a trend towards better outcomes for higher volume surgeons, but results must be interpreted with caution.

Epidemiology of Multiligament Knee Reconstruction

“…Although hospital identification numbers and physician license numbers are available in the database we used, the small overall sample size and small number of high-volume surgeons and hospitals (only 1.4% of surgeons and 3.9% of hospitals performed more than 20 reconstructions over the study period) precluded an analysis of the effects of hospital and surgeon volume on readmission or reoperation frequencies. However, previous studies suggest an association between surgeon and hospital case volume and perioperative mortality and morbidity and patient-reported outcomes for other orthopaedic procedures [17,28]. Considering the complexity of multiligament reconstruction, a similar association between volume and outcomes seems likely and is an important question for future research.…”

Does Operative Time Affect Infection Rate in Primary Total Knee Arthroplasty?

“…There are very limited data describing the relationship between surgeon procedure volume and the operative time required for TKA [11]. Most of the studies in the literature have studied the relationship between surgeon procedure volume and the outcomes of TKA [8,9,14].…”

“…Both surgeon-related and patient-related factors can contribute to increased operative times. Apart from operative time, other surgeon-related factors associated with PJI after TKA include surgeon case volume [14] and use of antibioticimpregnated cement [20]. Reported patient factors include male sex [13], preoperative comorbidities [13], diabetes mellitus [17], obesity [10,15,28], rheumatoid arthritis [26], and previous fractures about the knee [9].…”

Akteure der Versorgung

“…Maßnahmen (Haas et al 2013, Lau et al 2012, Schräder u. Ewerbeck 2007, Zenk et al 2014 (Jeschke et al 2013). …”

“…So zeigen Studien zum Hüft-und Kniegelenkersatz, dass sich die Fachkompetenz der Chirurgen auf die Komplikationsrate bei der Operation auswirken kann (Lau et al 2012, Zenk et al 2014. …”