Comparative Analysis of Total Knee Arthroplasty Outcomes Between Arthroplasty and Nonarthroplasty Fellowship Trained Surgeons

Orthopaedic Fellowship Match: How Do Degree and Gender Type Affect Match Success?

Introduction

Discrepancies have previously been identified in terms of gender and medical degree throughout orthopaedic education. The purpose of this study was to evaluate trends in the degree type and gender of applicants to orthopaedic trauma, sports medicine, adult reconstruction, foot and ankle, shoulder and elbow, and pediatric fellowships.

Methods

Official San Francisco match data from 2012 to 2023 were obtained. Data regarding the number of applicants, match rates, and rank list position based on applicant degree and gender were evaluated.

Results

The match rate for female applicants increased from a low of 81% (45/56) in 2013 to a high of 99% (94/95) in 2021 (mean 90% ± 6%), with a significant increase over the study period (r = 0.59, p = 0.02). For male applicants, the match rate ranged from a low of 85% (416/488) in 2013 to a high of 96% (515/536) in 2021 (mean 90% ± 4%), with a significant increase (r = 0.91, p = 0.000007). The match rate for osteopathic applicants increased from 63% (46/73) in 2013 to 94% (84/89) in 2021 (mean 82% ± 8%). There was a statistically significant increase in the match rate of osteopathic applicants over the study period (r = 0.75, p = 0.002). The match rate for allopathic applicants ranged from a low of 86% (405/471) in 2013 to a high of 96% (522/542) in 2021 (mean 91% ± 3%). There was a statistically significant increase in the match rate of allopathic applicants over the study period (r = 0.72, p = 0.003).

Conclusions

Overall, male and female applicants match at equal rates for the orthopaedic fellowship. Osteopathic graduates are less likely to match than allopathic graduates.

Does Orthopaedic Subspecialty Training Affect Treatment Decision-Making and Outcomes for Displaced Femoral Neck Fractures?

BACKGROUND

Approximately 1.3 to 2.2 million femoral neck fractures occur annually globally, with up to 80% being displaced, requiring hemiarthroplasty or total hip arthroplasty (THA). As the population ages, femoral neck fractures may surpass six million by 2050. Optimal treatment for displaced femoral neck fractures is debated with literature supporting both hemiarthroplasty and THA. Our objective was to determine if subspecialty training plays a role in the decision-making and outcomes of displaced femoral neck fractures.

METHODS

A retrospective analysis was performed for 386 patients who underwent hemiarthroplasty or THA for displaced femoral neck fracture at an academic health system from 2017 to 2023. To assess subspecialty training impact, patients were stratified based on training: adult reconstruction (AR) fellowship or other orthopaedic training (non-AR). Procedure duration, 90-day postoperative complications, length of stay, and discharge disposition were compared between cohorts. A subanalysis was performed to compare the procedures.

RESULTS

The AR surgeons performed THA 31.8% for femoral neck fractures compared to 10.5% for non-AR-trained surgeons (P < 0.001). Patients treated by AR-trained surgeons were on average younger (79 versus 82 years; P = 0.01). Procedure duration was shorter for hemiarthroplasty (80.4 versus 90.1 minutes; P = 0.01) and THA (94.9 versus 132.6 minutes; P = 0.01) when performed by AR surgeons (overall P = 0.01). The THA patients were more likely discharged home when treated by AR surgeons (55.3 versus 28%; P = 0.03). The AR-trained surgeons used cemented prostheses less compared to non-AR surgeons (16.9 versus 33.2%; P < 0.001).

CONCLUSIONS

Subspecialty training plays a role in decision-making, procedure duration, and discharge disposition for femoral neck fractures. The AR-trained surgeons more often perform THA for femoral neck fractures compared to non-AR-trained surgeons. The AR-trained surgeons completed hemiarthroplasty and THA in significantly shorter time compared with non-AR-trained surgeons and more frequently discharged patients home.

Total Joint Arthroplasty Outcomes in Eligible Patients Versus Patients Who Failed to Meet at Least 1 Eligibility Criterion: A Single-Center Retrospective Analysis

BACKGROUND

This study looks to investigate how not meeting eligibility criteria affects postoperative outcomes following total joint arthroplasty surgery.

METHODS

A retrospective review was conducted of total joint arthroplasty patients at a single academic institution. Demographics, laboratory values, and complications were recorded. Continuous and categorical variables were compared using the Student's T-test and the Chi-Square test, respectively. Multivariable analysis was used to control for confounding variables.

RESULTS

Our study included 915 total hip and 1,579 total knee arthroplasty patients. For total hip and total knee arthroplasty, there were no significant differences in complications (P = .11 and .87), readmissions (P = .83 and .2), or revision surgeries (P = .3 and 1) when comparing those who met all criteria to those who did not. Total hip arthroplasty patients who did not meet two criteria had 16.1 higher odds (P = .02) of suffering a complication. There were no differences in complications (P = .34 and .41), readmissions (P = 1 and .55), or revision surgeries (P = 1 and .36) between ineligible patients treated by total joint arthroplasty surgeons and those who were not. Multivariable analysis demonstrated no eligibility factors were associated with outcomes for both total hip and knee arthroplasty.

CONCLUSIONS

There was no significant difference in outcomes between those who met all eligibility criteria and those who did not. Not meeting two criteria conferred significantly higher odds of suffering a complication for total hip arthroplasty patients. Total joint arthroplasty surgeons had similar outcomes to non-total joint surgeons, although their patient population was more complex.

LEVEL OF EVIDENCE

III.

Fellowship Training in Arthroplasty Improves Treatment Success of Debridement, Antibiotics, and Implant Retention for Periprosthetic Knee Infections

Background

Debridement, antibiotics, and implant retention (DAIR) is a well-accepted surgical strategy for periprosthetic joint infection (PJI) following total knee arthroplasty (TKA). DAIR in TKA may be incorrectly thought of as a "simple" procedure not requiring formal specialized training in arthroplasty. Currently, there are no studies comparing the risk of treatment failure based on surgeon fellowship training.

Methods

A retrospective review was performed of consecutive patients who underwent DAIR for TKA PJI at our institution. Two cohorts were created based on whether DAIR was performed by an arthroplasty fellowship-trained (FT) surgeon or nonarthroplasty fellowship-trained (NoFT) surgeon. Primary outcome was treatment failure following DAIR at a minimum of 1 year postoperatively. Treatment failure was based on the Tier 1 International Consensus Meeting definition of infection control. Secondary outcomes were also recorded including death during the totality of PJI treatment.

Results

A total of 112 patients were identified (FT = 68, NoFT = 44). At a mean follow-up of 7.3 years [standard deviation = 3.9], 73 patients (59.8%) failed treatment. Fellowship training in arthroplasty significantly improved treatment success rates (FT, 35/68 [51.5%]; NoFT, 10/44 [22.7%]; odds ratio 2.5 [95% confidence interval 1.1 to 5.9; P = .002]). Survivorship also differed significantly between the cohorts; at timepoints of 1.5 months, 5 months, 30 months, and 180 months, survivorship of the FT cohort was 79.4%, 67.6%, 54.4%, and 50.7%, respectively, compared with a survivorship of 65.9%, 52.3%, 25%, and 22.7% in the NoFT cohort (P = .002).

Conclusions

TKA PJI treated with DAIR should not be considered a simple procedure. Improved treatment success may be associated with subspecialty fellowship training in arthroplasty.

Level of Evidence

IV.

Adult Reconstruction Surgeons Manage Patients With Higher Medical Complexities and Still Achieve Comparable Outcomes to Sports Medicine Surgeons Following Total Knee Arthroplasty

Background

Orthopaedic surgeons who are fellowship-trained in adult reconstruction (AR) specialize specifically in total joint arthroplasty, including total knee arthroplasty (TKA). However, TKA procedures are not only performed by AR surgeons. The purpose of this study was to compare the patient demographics and postoperative outcomes of patients who had a TKA procedure performed by an AR surgeon vs a sports medicine (SM) surgeon.

Methods

A retrospective cohort study was conducted using a national insurance database. Patients who underwent a primary elective TKA procedure by an AR surgeon (n = 56,570) and an SM surgeon (n = 72,888) were identified. Patient demographics, rates of joint complications within 2 years, and medical complications within 90 days postoperatively were compared using multivariable logistic regression.

Results

Compared to the cohort of patients undergoing TKA by SM surgeons, the patient cohort of AR surgeons had a higher mean Elixhauser comorbidity index (4.2 vs 4.0, P < .001), and had significantly higher rates of several comorbidities. Within 90 days, patients of AR surgeons demonstrated significantly lower rates of acute kidney injury and transfusions. When compared to patients of SM surgeons, patients of AR surgeons demonstrated significantly lower rate of manipulation under anesthesia or lysis of adhesions within 2 years. Rates of all other joint-related complications were statistically comparable between the 2 cohorts.

Conclusions

As a cohort, AR surgeons perform TKA on a higher-risk cohort of patients compared to sports medicine surgeons. Despite the higher-risk patient population, outcomes of TKA by AR surgeons appear equivalent compared to their SM colleagues.

Learning curve for imageless robotic-assisted total knee arthroplasty in non-fellowship trained joint replacement surgeons

Introduction

Robotic-assisted total knee arthroplasty (RA-TKA) has become increasingly popular, although an associated learning curve can be a deterrent for some surgeons. Prior studies have addressed this learning curve in fellowship-trained arthroplasty surgeons, however the learning curve among non-fellowship-trained surgeons remains unclear. The objective of this study was to investigate the learning curve for imageless RA-TKA related to operative time and rates of complications among two non-arthroplasty-trained orthopedic surgeons.

Methods

This retrospective case series included 200 RA-TKA consecutive cases performed by two non-arthroplasty-trained orthopedic surgeons (100 each). Cases were divided into 2 cohorts for each surgeon: the first 50 consecutive cases and the second 50 cases. These cohorts were then compared to assess for trends in each surgeon as well as in both surgeons combined. Mean operative times were compared, as were hospital length of stay, complications, readmission, and reoperations.

Results

For both surgeons, the mean operative time significantly decreased from the first 50 cases to the next 50 cases (116.5 vs 108.4 min for surgeon 1, P = 0.031; 125.7 vs 109.1 min for surgeon 2, P = 0.001). No significant differences were found among length of stay, complications, readmissions, or reoperations between cohorts.

Conclusion

General orthopedic surgeons can expect to optimize operative time within 50 cases, while not carrying associated risks of related complications during the early learning period.

Racial Disparities in Rates of Revision and use of Modern Features in Total Knee Arthroplasty, a National Registry Study

BACKGROUND

The purpose of our study was to investigate the association of race and ethnicity with rates of modern implant use and postoperative outcomes in total knee arthroplasty (TKA) using the American Academy of Orthopaedic Surgeons American Joint Replacement Registry.

METHODS

Adult TKAs from 2012 to 2020 were queried from the American Joint Replacement Registry. A total of 1,121,457 patients were available for analysis for surgical features and 1,068,210 patients for analysis of outcomes. Mixed-effects multivariable logistic regression models were used to examine the association of race with each individual surgical feature (unicompartmental knee arthroplasty (UKA) and robotic-assisted TKA (RA-TKA)) and 30- and 90-day readmission. A proportional subdistribution hazard model was used to model the risk of revision TKA.

RESULTS

On multivariate analyses, compared to White patients, Black (odds ratio (OR): 0.52 P < .0001), Hispanic (OR 0.75 P < .001), and Native American (OR: 0.69 P = .0011) patients had lower rates of UKA, while only Black patients had lower rates of RA-TKA (OR = 0.76 P < .001). White (hazard ratio (HR) = 0.8, P < .001), Asian (HR = 0.51, P < .001), and Hispanic-White (HR = 0.73, P = .001) patients had a lower risk of revision TKA than Black patients. Asian patients had a lower revision risk than White (HR = 0.64, P < .001) and Hispanic-White (HR = 0.69, P = .011) patients. No significant differences existed between groups for 30- or 90-day readmissions.

CONCLUSION

Black, Hispanic, and Native American patients had lower rates of UKA compared to White patients, while Black patients had lower rates of RA-TKA compared to White, Asian, and Hispanic patients. Black patients also had higher rates of revision TKA than other races.

Complications, Implant Survivorships, and Functional Outcomes of Conversion Total Knee Arthroplasty With Prior Hardware

BACKGROUND

End-stage knee osteoarthritis with retained periarticular hardware is a frequent scenario. Conversion total knee arthroplasty (TKA) leads to excellent outcomes, but poses unique challenges. The evidence supporting retention versus removal of hardware during TKA is controversial.

METHODS

Patients who underwent TKA with prior hardware between January 2009 and December 2019 were identified. A total of 148 patients underwent TKA with prior hardware. The mean follow-up was 60 months (range, 24-223). Univariate and multivariable analyses were used to study correlations among factors and surgical-related complications, prosthesis failures, and functional outcomes.

RESULTS

The complication rate was 28 of 148 (18.9%). The use of a quadriceps snips in addition to a medial parapatellar arthrotomy was associated with a higher complication (odds ratio: 20.7, P < .05), implant failures (odds ratio: 13.9, P < .05), and lower the Veterans Rand 12 Mental Score (VR-12 MS) (-14.8, P < .05). Hardware removal versus retention and use of single versus multiple incisions were not associated with complications or prosthesis failures. Removal of all hardware was associated with significantly higher (+7.3, P < .05) VR-12 MS compared to retention of all hardware.

CONCLUSIONS

TKA with prior hardware was associated with more complications, implant failures, and lower VR-12 MS when a more constrained construct or quadriceps snip was performed. This probably reflects the level of difficulty of the procedure rather than the surgical approach used. Hardware removal or retention was not associated with complications or implant failures; however, removal rather than retention of all prior hardware is associated with increased general health outcomes.

LEVEL OF EVIDENCE

IV, cohort without control.

Surgical Benchmarks for ACGME-accredited Adult Reconstructive Orthopaedic Fellowship Training

INTRODUCTION

Higher case volumes correlate with improved outcomes in total joint arthroplasty surgery. The purpose of this study was to understand the effect of adult reconstruction fellowship training on reported case volume in a contemporary cohort of orthopaedic surgeons.

METHODS

The Accreditation Council for Graduate Medical Education provided case logs for orthopaedic surgery residents and adult reconstructive orthopaedic fellows from 2017 to 2018 to 2020 to 2021. Reported case volumes for total joint arthroplasty surgeries were compared using Student t tests.

RESULTS

One hundred eighty-three adult reconstructive orthopaedic fellows and 3,000 orthopaedic surgery residents were included. Residents reported more total hip arthroplasty cases (98.9 ± 30 to 106.1 ± 33, 7.3% increase, P < 0.05) and total knee arthroplasty cases (126.0 ± 41 to 136.5 ± 44, 8.3% increase, P < 0.05) over the study period. On average, fellows reported 439.6 total cases: primary total knee arthroplasty, 164.9 cases (37.5%); primary total hip arthroplasty, 146.8 cases (33.4%); revision total knee arthroplasty, 35.2 cases (8.0%); revision total hip arthroplasty, 33.0 cases (7.5%); unicompartmental knee arthroplasty, 4.4 cases (1.0%); and other, 55.0 cases (12.5%). Overall, adult reconstructive orthopaedic fellowship reported between 1.7- and 2.0-fold more joint arthroplasty cases during 1 year of fellowship training than 5 years of residency ( P < 0.001).

DISCUSSION

Adult reconstructive orthopaedic fellowship training provides notable exposure to additional cases after residency training. The results from this study may inform prospective applicants on the effect of fellowship training in total joint arthroplasty and help establish benchmarks in case volume for independent practice.

Surgeons Experience Greater Cardiorespiratory Strain and Stress During Total Hip Arthroplasty Than Total Knee Arthroplasty

BACKGROUND

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are physically demanding, with a high prevalence of work-related injuries among arthroplasty surgeons. It is unknown whether there are differences in cardiorespiratory output for surgeons while performing THA and TKA. The objective of this study is to characterize whether differences in surgeon physiological response exist while performing primary THA vs TKA.

METHODS

This is a prospective cohort study including 3 high-volume, fellowship-trained arthroplasty surgeons who wore a smart garment that recorded cardiorespiratory data on operative days during which they were performing primary conventional TKA and THA. Variables collected included patient body mass index (BMI), operative time (minutes), heart rate, heart rate variability, respiratory rate, minute ventilation, and energy expenditure (calories).

RESULTS

Seventy-six consecutive cases (49 THAs and 27 TKAs) were studied. Patient BMI was similar between the 2 cohorts (P > .05), while operative time was significantly longer in TKAs (60.4 ± 12.0 vs 53.6 ± 11.8; P = .029). During THA, surgeons had a significantly higher heart rate (95.7 ± 9.1 vs 90.2 ± 8.9; P = .012), energy expenditure per minute (4.6 ± 1.23 vs 3.8 ± 1.2; P = .007), and minute ventilation (19.0 ± 3.0 vs 15.5 ± 3.3; P < .001) compared to TKA.

CONCLUSION

Surgeons experience significantly higher physiological strain and stress while performing THA. While scheduling THAs and TKAs, surgeons should consider the higher physical demand associated with THAs and ensure adequate personal preparation and sequence of cases.