Abstract
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 until October 6th, 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-Meir 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 (five THR studies, two TKR studies, and two UKR studies). The pooled net implant survival estimates for THRs at five 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 five and ten 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 ten 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 to consultants, in terms of the net survival or crude revision rate of hip and knee replacements at five to ten 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.
Design: A systematic review and meta-analysis of observational studies.
Data sources: MEDLINE® and Embase® from inception until October 6th, 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-Meir 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 (five THR studies, two TKR studies, and two UKR studies). The pooled net implant survival estimates for THRs at five 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 five and ten 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 ten 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 to consultants, in terms of the net survival or crude revision rate of hip and knee replacements at five to ten 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.
| Original language | English |
|---|---|
| Article number | e047882 |
| Journal | BMJ Open |
| Volume | 11 |
| Issue number | 11 |
| DOIs | |
| Publication status | Published - 10 Nov 2021 |
Bibliographical note
Funding Information:Competing interests AWB and MRW declare support from The Healthcare Quality Improvement Partnership/The NJR in the form of the Lot 2 contract for statistical analysis of the NJR, outside the submitted work; AWB and MRW report grants from the NIHR investigating the outcomes of joint replacement, outside the submitted work; AWB and MRW are editors of an Orthopaedic textbook for which they receive royalty payments from Taylor Francis; MRW reports fees paid to their institution for delivering teaching at courses organised by DePuy and Heraeus. Patient consent for publication Not applicable. Provenance and peer review Not commissioned; externally peer reviewed.
Funding Information:
Funding This study was supported by the National Institute for Health Research (NIHR) Bristol Biomedical Research Centre at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol (grant number: N/A). TJF was supported by an NIHR Academic Clinical Fellowship. AS was supported by an MRC strategic skills fellowship (grant number: MR/L01226X/1).
Publisher Copyright:
©