Residents' Learning Curve of Total Knee Arthroplasty Based on Radiological Outcome Parameters: A Retrospective Comparative Study

An Advanced Knee Simulator Model Can Reproducibly Be Used for Ligament Balancing Training during Total Knee Arthroplasty

A critical and difficult aspect of total knee arthroplasty (TKA) is ligamentous balancing for which cadavers and models have played a large role in the education and training of new arthroplasty surgeons, although they both have several shortcomings including cost, scarcity, and dissimilarity to in vivo ligament properties. An advanced knee simulator (AKS) model based on computed tomography (CT) scans was developed in the setting of these challenges with cadavers and previous models. In this study, we compared the ligament balancing between AKS and human cadaveric knees to assess the validity of using the AKS for ligament balancing training during TKA. A CT scan of a TKA patient with varus deformity was used to design the AKS model with modular components, using three-dimensional printing. Three fellowship-trained arthroplasty surgeons used technology-assisted TKA procedure to plan and balance three cadaver knees and the AKS model. Medial and lateral laxity data were captured using manual varus and valgus stress assessments for cadavers and the model in an extension pose (10 degrees of flexion from terminal extension) and between 90 and 95 degrees for flexion. After preresection assessments, surgeons planned a balanced cruciate-retaining TKA. Following bony cuts and trialing, extension and flexion ligament laxity values were recorded in a similar manner. Descriptive statistics and Student's t-tests were performed to compare the cadavers and model with a p-value set at 0.05. Preresection medial/lateral laxity data for both extension and flexion were plotted and showed that the highest standard deviation (SD) for the cadavers was 0.67 mm, whereas the highest SD for the AKS was 1.25 mm. A similar plot for trialing demonstrated that the highest SD for the cadavers was 0.6 mm, whereas the highest SD for the AKS was 0.61 mm. The AKS trialing data were highly reproducible when compared with cadaveric data, demonstrating the value of the AKS model as a tool to teach ligament balancing for TKA and for future research endeavors.

Evaluation of a radiological grading system for the early detection of total knee arthroplasties at risk for revision surgery

INTRODUCTION

X-rays are regularly performed after primary total knee arthroplasty (TKA). While soft tissue management and ligament tension cannot be evaluated, important information, such as inadequate component positioning and loose cement location, as well as subsequent loosening, can be detected. The aim of this study was to correlate radiological findings, referring to the radiological grading system (previously published by the same study group, henceforth abbreviated as "RGS"), with long-term outcomes and implant survival.

MATERIALS AND METHODS

A total of 266 patients who underwent titanium-coated TKA were included. In addition to implant survival, visual analogue scale score, Tegner activity score, knee society score (KSS), Western Ontario and McMaster Universities Osteoarthritis Index, and short form-12 score as well as range of motion were evaluated. Clinical examination as well as anterior-posterior, lateral, full-length weight bearing, and patellar view radiographs were performed pre- and postoperatively, at the 3-, 6-, and 12-month postoperative follow-ups and at the final follow-up. The radiological grading system was evaluated and correlated with long-term outcome and survivorship.

RESULTS

The revision-free survival rate was 88.4% at a median follow-up of 9.8 years (IQR: 9.3-10.3 years; range: 0.1-11.8 years). Revision surgery was required in 31 TKAs (11.7%). The multivariate Cox regression model showed a significant association between an RGS score ≥ 3 deviation points (DP) and an increased risk for revision (hazard ratio: 2.092; 95% CI: 1.020-4.290; p = 0.044). Moreover, the KSS for pain was significantly worse in patients with a RGS score ≥ 3 DP (median, 85 [74-92] vs. 90 [80-94]; p = 0.007).

CONCLUSIONS

This is the first study indicating that deviation in component positioning, having an inadequate long leg axis, the presence of free cement or residual bony structures on postoperative X-rays significantly correlate with TKA outcome and implant survival. Therefore RGS can be of high predicable value for the survivorship of the prosthesis.

LEVEL OF EVIDENCE

Level IV - retrospective cohort study.

Learning curve of Persona Partial Knee (PPK) arthroplasty: a clinical trial

BACKGROUND

Unicompartmental knee arthroplasty (UKA) procedures are considered to be more technically demanding than conventional total knee arthroplasty (TKA), requiring a longer learning curve and more expert surgical skills. Despite some clear advantages of UKA over TKA (such as lesser blood loss, greater bone stock, greater knee performances, etc.), UKA evidenced a greater rate of revision.

OBJECT

This study investigated the learning curve of Persona Partial Knee (PPK) arthroplasty for primary medial UKA performed by a single, non-designer surgeon. PPK is a fixed-bearing, compartment-specific implant. The primary outcome of interest for this study was to evaluate the learning curve of the surgical duration. The secondary outcome of interest was to evaluate the learning curve of radiological implant positioning.

METHODS

Patients who underwent primary medial UKA using PPK (Zimmer-Biomet, Warsaw IN, USA) were prospectively enrolled for the study. All surgeries were performed by a single, non-designer surgeon experienced in knee and hip arthroplasty. The primary outcome of interest was to evaluate the surgical duration. The secondary outcome of interest was to evaluate the implant positioning. The learning curve was estimated using an appropriate nonlinear polynomial regression model with a lower Akaike Information Criterion (AIC).

RESULTS

One hundred twenty five patients were enrolled in the study. 59% of them (74 of 125 patients) were women. The patients' mean age at the time of surgery was 70.1 ± 9.5 years and their mean body mass index (BMI) was 27.8 ± 4.2 kg/m2. Curve stabilisation of the surgical time was at the 94th patient, of the tibial angle at the 47th patient, of the tibial slope at the 54th patient, of the anterior protrusion at the 29th patient, and of the posterior protrusion at the 51st patient.

CONCLUSIONS

The learning curve for component positioning was achieved in approximately 50 cases. The curve of the surgical time achieved a plateau at 94 Persona Partial Knee. Additionally, the factors directly correlated with earlier stabilization of the learning curve in terms of component positioning were: male gender, younger age, right side, and larger components.

Learning curve of total ankle arthroplasty: a systematic review

INTRODUCTION

Together with ankle arthrodesis, total ankle arthroplasty is now accepted as a first-line intervention in the management of end-stage arthritis of the ankle. The evidence regarding how outcomes are affected by surgeon experience is inconsistent; we performed a systematic review to evaluate the effect of a learning curve in total ankle arthroplasty outcomes.

METHODS

An electronic database search was performed in PubMed, Embase, ISI Web of Science and Cochrane trials. Two reviewers independently conducted a two-stage title/abstract and full text screening. English-language original research studies comparing patient-reported outcome measures (PROMs), complication/revision rates, operative time, length of stay or radiation exposure according to surgeon experience were included. Quality assessment was performed using the methodological index for non-randomised studies.

RESULTS

All but one included study report either improved PROMs, reduced complication/revision rate, reduced hospital stay length/operative time or reduced radiation exposure with increasing surgeon experience. However, the majority of these findings lack statistical significance. Two studies assessing the plateau of the learning curve report a wide range of plateau thresholds between 9 and 39 cases.

CONCLUSION

This review finds a largely non-significant trend towards improvements in PROMs, complication, and revision rates with improved surgeon experience. The lack of statistical significance in a number of studies may be partially explained by methodological flaws, with more suitably designed studies reporting significant improvements. Future research into the effect of advancements in implant design and insertion guides is required to further characterise the magnitude of the learning curve and guide both mitigation and learning strategies.

Extended-wavelength diffuse reflectance spectroscopy dataset of animal tissues for bone-related biomedical applications

Diffuse reflectance spectroscopy (DRS) has been extensively studied in both preclinical and clinical settings for multiple applications, notably as a minimally invasive diagnostic tool for tissue identification and disease delineation. In this study, extended-wavelength DRS (EWDRS) measurements of ex vivo tissues ranging from ultraviolet through visible to the short-wave infrared region (355-1919 nm) are presented in two datasets. The first dataset contains labelled EWDRS measurements collected from bone cement samples and ovine specimens including 10 tissue types commonly encountered in orthopedic surgeries for data curation purposes. The other dataset includes labelled EWDRS measurements of primarily bone structures at different depths during stepwise drilling into intact porcine skulls until plunging into the cranial cavity. The raw data with code for pre-processing and calibration is publicly available for reuse on figshare. The datasets can be utilized not only for exploratory purposes in machine learning model construction, but also for knowledge discovery in the orthopedic domain to identify important features for surgical guidance, extract physiological parameters and provide diagnostic insights.

Resident Impact on Primary Total Knee Arthroplasty: A Consecutive Series Under a Single Surgeon

Background

The literature has displayed conflicting evidence on resident involvement in surgical procedures. The goal of this study was to assess the impact of resident involvement on primary total knee arthroplasty (TKA) under a single fellowship-trained adult reconstruction surgeon.

Methods

Two hundred sequential patients were retrospectively reviewed by a single surgeon: the first cohort represented the final 100 TKAs performed by the surgeon without resident involvement (NRI), serving as the control group, and the second cohort represented the initial 100 TKAs performed by the same surgeon with resident involvement (RI), serving as the experimental group. Perioperative variables such as number of people in operating room (OR), surgical time, and tourniquet time, and postoperative variables such as infection, minor complications, medial distal femoral angle, medial proximal tibia angle, and total angulation were assessed.

Results

The rate of infection was significantly lower in the RI group (0%) compared to the NRI group (1%) (P = .043). The number of staff in the OR (P < .001), the tourniquet time (P < .001), and OR time (P < .001) were significantly higher in the RI group compared to the NRI group. There was no difference in coronal plane radiographic measurements: medial distal femoral angle (P = .10), medial proximal tibia angle (P = .19), or total angulation (P = .27).

Conclusions

Resident involvement in primary TKA neither demonstrated any significant difference in coronal plane radiographic alignment of the prosthesis nor an increased risk of infection despite increased operative time, tourniquet time, and number of people in OR.

Level of evidence

Level 3 - Therapeutic retrospective cohort study.

3D-printed, patient-specific cutting guides improve femoral and tibial cut alignment in canine total knee replacement

OBJECTIVES

The purpose of this cadaveric study was to determine whether patient-specific guides (PSGs) improve the accuracy of tibial and femoral cut alignment in canine total knee replacement (TKR), as compared with generic cutting guides.

STUDY DESIGN

Original research.

ANIMALS

Sixteen pelvic limbs from skeletally mature medium- to large-breed canine cadavers.

METHODS

Specimens were randomly allocated to one of two groups (PSG or Generic; N = 8/group). In the Generic group, femoral and tibial ostectomies were made using the standard canine TKR femoral cutting blocks and tibial alignment guide. In the PSG group, the cuts were made using a series of custom 3D-printed cutting guides. "Planned" and "actual" tibial and femoral cut alignments were compared in the frontal and sagittal planes, and errors were calculated by subtracting actual from planned values.

RESULTS

Use of 3D-printed PSGs improved tibial cut alignment in the frontal plane but not the sagittal plane. PSGs also improved the alignment of the cranial and distal femoral ostectomies but did not impact varus-valgus alignment.

CONCLUSIONS

These findings support the use of PSGs for TKR in dogs. Clinical trials are now needed to determine whether the benefits of PSGs translate into measurable improvements in joint function and implant longevity.

CLINICAL SIGNIFICANCE

PSGs have the potential to improve femoral and tibial component alignment in canine TKR.

Assessment of Team Dynamics and Operative Efficiency in Hip and Knee Arthroplasty

Importance

Surgical team communication is a critical component of operative efficiency. The factors underlying optimal communication, including team turnover, role composition, and mutual familiarity, remain underinvestigated in the operating room.

Objective

To assess staff turnover, trainee involvement, and surgeon staff preferences in terms of intraoperative efficiency.

Design, Setting, and Participants

Retrospective analysis of staff characteristics and operating times for all total joint arthroplasties was performed at a tertiary academic medical center by 5 surgeons from January 1 to December 31, 2018. Data were analyzed from May 1, 2021, to February 18, 2022. The study included cases with primary total hip arthroplasties (THAs) and primary total knee arthroplasties (TKAs) comprising all primary total joint arthroplasties performed over the 1-year study interval.

Exposures

Intraoperative turnover among nonsurgical staff, presence of trainees, and presence of surgeon-preferred staff.

Main Outcomes and Measures

Incision time, procedure time, and room time for each surgery. Multivariable regression analyses between operative duration, presence of surgeon-preferred staff, and turnover among nonsurgical personnel were conducted.

Results

A total of 641 cases, including 279 THAs (51% female; median age, 64 [IQR, 56.3-71.5] years) and 362 TKAs (66% [238] female; median age, 68 [IQR, 61.1-74.1] years) were considered. Turnover among circulating nurses was associated with a significant increase in operative duration in both THAs and TKAs, with estimated differences of 19.6 minutes (SE, 3.5; P < .001) of room time in THAs and 14.0 minutes (SE, 3.1; P < .001) of room time in TKAs. The presence of a preferred anesthesiologist or surgical technician was associated with significant decreases of 26.5 minutes (SE, 8.8; P = .003) of procedure time and 12.6 minutes (SE, 4.0; P = .002) of room time, respectively, in TKAs. The presence of a surgeon-preferred vendor was associated with a significant increase in operative duration in both THAs (26.3 minutes; SE, 7.3; P < .001) and TKAs (29.6 minutes; SE, 9.6; P = .002).

Conclusions and Relevance

This study found that turnover among operative staff is associated with procedural inefficiency. In contrast, the presence of surgeon-preferred staff may facilitate intraoperative efficiency. Administrative or technologic support of perioperative communication and team continuity may help improve operative efficiency.

The impact of surgical trainee involvement in total knee arthroplasty: a systematic review of surgical efficacy, patient safety, and outcomes

PURPOSE

Trainee involvement in patient care has raised concerns about the potential risk of adverse outcomes and harming patients. We sought to analyze the impact and potential consequence of surgical trainee involvement in total knee arthroplasty (TKA) procedures in terms of surgical efficacy, patient safety, and functional outcomes.

METHODS

We systematically reviewed Medline/PubMed, EMBASE, the Cochrane library, and Scopus databases in April 2021. Eligible studies reported on the impact of trainee participation in TKA procedures performed with and without such involvement.

RESULTS

Twenty-three publications met our eligibility criteria and were included in our study. These studies reported on 132,624 surgeries completed on 132,416 patients. Specifically, 23,988 and 108,636 TKAs were performed with and without trainee involvement, respectively. The mean operative times for procedures with (n = 19,573) and without (n = 94,581) trainee involvement were 99.77 and 85.05 min, respectively. Both studies that reported data on cost of TKAs indicated a significant increase (p < 0.001) associated with procedures completed by teaching hospitals compared to private practices. Mean overall complication rates were 7.20% and 7.36% for TKAs performed with (n = 9,386) and without (n = 31,406) trainees. Lastly, the mean Knee Society Scale (KSS) knee scores for TKAs with (n = 478) and without (n = 806) trainee involvement were similar; 82.81 and 82.71, respectively.

CONCLUSION

Our systematic review concurred with previous studies that reported trainee involvement during TKAs increases the mean operative time. However, the overall complication rates and functional outcomes were similar. Larger studies with a better methodology and higher level of evidence are still needed for a resolute conclusion.

Does Resident Participation Influence Surgical Time and Clinical Outcomes? An Analysis on Primary Bilateral Single-Staged Sequential Total Knee Arthroplasty

Background

Although several studies have indirectly compared teaching and nonteaching hospitals, results are conflicting, and evaluation of the direct impact of trainee involvement is lacking. We investigated the direct impact of resident participation in primary total knee arthroplasties (TKAs).

Material and methods

Fifty patients undergoing single-staged sequential bilateral primary TKAs were evaluated. The more symptomatic side was performed by the attending surgeon first, followed by the contralateral side performed by a chief resident under direct supervision and assistance of the same attending surgeon. Surgery was subdivided into 8 critical steps on both sides. The overall time and critical stepwise surgical time and short-term clinical outcomes were then compared between the 2 sides.

Results

The attending surgeon completed the surgery (skin incision to dressing) significantly faster than the resident (70.2 vs 96.9 minutes) by a mean of 26.7 minutes (P < .05) and was also faster in all steps. The most significant differences in time were in “exposure” (9.5 vs 16.5 minutes) and “closure” steps (13.2 vs 24.9 minites), all P < .001. Adverse events occurred in 7 patients; 5 of these resolved uneventfully. There were no significant differences in surgical complications, objective outcome scores, or patient satisfaction scores between both sides.

Conclusion

Resident participation in TKA increased operative time without jeopardizing short-term patient clinical outcomes, satisfaction, and complications. This may alleviate concerns from patients and policymakers about TKA in an academic setting. Surgical “exposure” and “closure” were the most prolonged steps for the residents, and they may benefit with more focus and/or simulation studies during training.

Virtual and augmented reality for surgical training and simulation in knee arthroplasty

BACKGROUND

Immersive virtual reality (IVR), augmented reality and mixed reality form a spectrum of extended reality technology integration that has gained popularity in orthopaedics recently. This review article examines the role of extended reality technologies in knee arthroplasty.

METHODS

Existing literature on the applications of extended reality technologies in preoperative planning and intraoperative navigation were reviewed. A sample workflow of a novel IVR simulator for improving surgical training was also provided to demonstrate its utility in educating trainees on knee arthroplasty techniques.

RESULTS

Extended reality technologies enable the surgeon to visualise patient-specific anatomy in real-time, enhancing preoperative planning and providing intraoperative guidance. IVR technology has the potential to revolutionise modern surgical training and optimise surgical performance in a cost-efficient manner, with current evidence demonstrating favourable immediate skill acquisition and transfer.

CONCLUSIONS

Extended reality technologies have a myriad of potential applications in orthopaedic surgery. Further research is needed to evaluate the cost-effectiveness of its incorporation into training programmes.