Key performance and training parameters in primary total hip arthroplasty - an expert consensus using the Delphi technique

The risk of revision surgery after trainee-led primary total hip replacement

INTRODUCTION

The aim of this study was to determine the impact of operating surgeon grade and level of supervision on the incidence of one-year patient mortality and all-cause revision following elective primary total hip replacement (THR).

METHODS

National Joint Registry data from 2005 to 2020 for a single University Teaching Hospital were used, with analysis performed on the 15-year dataset divided into 5-year block periods (B1, 2005-2010; B2, 2010-2015; B3, 2015-2020). Outcome measures were mortality and revision surgery at one year, in relation to lead surgeon grade, and level of supervision for trainee-led (TL) operations.

RESULTS

A total of 9,999 eligible primary THRs were performed, of which 5,526 (55.3%) were consultant-led (CL), and 4,473 (44.7%) TL. Of TL, 2,404 (53.7%) were nonconsultant-supervised (TU) and 2,069 (46.3%) consultant-supervised (TS). The incidence of one-year patient mortality was 2.05% (n=205), and all-cause revision was 1.11% (n=111). There was no difference in one-year mortality between TL and CL operations (p=0.20, odds ratio (OR) 0.78, confidence interval (CI) 0.55-1.10). The incidence of one-year revision was not different for TL and CL operations (p=0.15, OR 1.37, CI 0.89-2.09). Overall, there was no temporal change for either outcome measure between TL or CL operations. A significant increase in revision within one-year was observed in B3 between TU compared with CL operations (p=0.005, OR 2.81, CI 1.35-5.87).

CONCLUSIONS

We found no difference in overall one-year mortality or all-cause revision rate between TL and CL primary THR. Despite a reduction in unsupervised THR in the latest five-year period (2015-2020), unsupervised TL THR resulted in an increased risk of early revision.

Acetabular cup size trends in total hip arthroplasty

BACKGROUND

Total hip arthroplasty (THA) is a common procedure for end stage osteoarthritis. The learning curve for THA is complex and challenging. One of the most difficult skills to master is acetabular reaming. We wish to identify if experience in arthroplasty leads to preservation of more bone stock.

AIM

To investigate if increasing surgeon experience will predict an ever decreasing acetabular cup size.

METHODS

A retrospective case series of four attending orthopaedic surgeons was completed. All uncemented elective total hip arthroplasties since appointment were selected for inclusion. The size of acetabular cup used was noted and logistic regression was used to identify if a trend to smaller cups existed.

RESULTS

A total of 1614 subjects were included with a mean age of 64 years. Overall cups were on average 0.18mm smaller per year (95% confidence interval -0.25 to -0.11, P < 0.001). Individual surgeon trends showed cup sizes to decrease 0.27 mm/year for surgeon A, 0.02 mm/year for surgeon B, 0.15 mm/year for surgeon C and 0.29 mm/year for surgeon D. Three of the four surgeons had a more pronounced trend to smaller cups for male subjects than their female counterparts.

CONCLUSION

We found increasing surgeon experience to be associated with an ever-decreasing acetabular cup size. Smaller acetabular cup size may act as a surrogate marker of surgical proficiency by virtue of decreased acetabular reaming.

Validating the accuracy of a novel virtual reality platform for determining implant orientation in simulated primary total hip replacement

Introduction

Accurate acetabular cup and femoral stem component orientation are critical for optimising patient outcomes, reducing complications and increasing component longevity following total hip replacement (THR). This study aimed to determine the accuracy of a novel virtual reality (VR) platform in assessing component orientation in a simulated THR model.

Methods

The VR platform (HTC Vive Pro® system hardware) was compared against the validated Vicon® optical motion capture (MoCap) system. An acetabular cup and femoral stem were manually implanted across a range of orientations into pelvic and femur sawbones, respectively. Simultaneous readings of the acetabular cup operative anteversion (OA) and inclination (OI) and femoral stem alignment (FSA) and neck anteversion (FNA) were obtained from the VR and MoCap systems. Statistical analysis was performed using Pearson product-moment correlation coefficient (PPMCC) (Pearson’s r) and linear regression (R²).

Results

A total of 55 readings were obtained for the acetabular cup and 68 for the femoral stem model. The mean average differences in OA, OI, FSA and FNA between the systems were 3.44°, −0.01°, 0.01° and −0.04°, respectively. Strong positive correlations were demonstrated between both systems in OA, OI, FSA and FNA, with Pearson’s r = 0.92, 0.94, 0.99 and 0.99, and adjusted R² = 0.82, 0.9, 0.98 and 0.98, respectively.

Conclusion

The novel VR platform is highly accurate and reliable in determining both acetabular cup and femoral stem component orientations in simulated THR models. This adaptable and cost-effective digital tracking platform may be modified for use in a range of simulated surgical training and educational purposes, particularly in orthopaedic surgery.