Novais Eduardo N, Carry Patrick M, Kestel Lauryn A, Ketterman Brian, Brusalis Christopher M, Sankar Wudbhav N
Department of Orthopaedic Surgery, Boston Children's Hospital, 300 Longwood Avenue, Hunnewell Building, Boston, MA, 02215, USA.
Musculoskeletal Research Center, Department of Orthopaedic Surgery, Children's Hospital Colorado, Aurora, CO, USA.
Clin Orthop Relat Res. 2017 Apr;475(4):1110-1117. doi: 10.1007/s11999-016-5010-1.
Bernese periacetabular osteotomy (PAO) is a technically challenging procedure with potential risk for major complications and a previously reported steep learning curve. However, the impact of contemporary hip preservation fellowships on the learning curve of PAO has not been established.
QUESTIONS/PURPOSES: (1) What was the frequency of major complications during the PAO learning curve of two surgeons who recently graduated from hip preservation fellowships? (2) Is increasing level of experience associated with the risk of a complication and with operative time, a possible surrogate measure of surgical performance?
We retrospectively studied 81 PAOs performed by one of two surgeons who recently graduated from a hip preservation fellowship during their first 4 years of practice in two institutions. One of the surgeons participated as a fellow in 78 PAOs with an increasing level of responsibility during the course of 1 full year. The other surgeon performed 41 PAOs as a fellow during 6 months, also with an increasing level of responsibility during that time. There were 68 (84%) female and 13 (16%) male patients (mean age, 18 years; range, 10-36 years). The frequency of complications was recorded early and at 1 year after surgery and graded according to a validated classification system describing five grades of complications. Complications that required surgical intervention (Grade III) and life-threatening complications (Grade IV) were considered major complications. Persistent pain after surgery, although considered a failure of PAO, was not considered a surgical complication as a result of the multifactorial etiology of pain after hip-preserving surgery. However, early reoperation and revision surgery were counted as complications. To evaluate the association between increasing level of experience and the occurrence of complications, we divided each surgeon's experience into his first 20 procedures (initial interval) and his second 20 (experienced interval) to test whether the incidence of complications or operative time was different between the two intervals. Because the association between experience and the likelihood of a complication was estimated to be consistent between the two surgeons, the analysis was performed with data pooled from the two surgeons. To test whether there was a difference in the likelihood of a complication in the initial and the experienced intervals, a multivariate logistic regression analysis was performed and the adjusted risk of a complication between the two intervals was calculated. Linear regression analyses were used to test the association between surgeon level of experience and operative time.
The overall incidence of major (Grade III or Grade IV) complications was 6% (95% confidence interval [CI], 2%-14%). These included deep infection (3% [three of 81]), intraoperative posterior column fracture (1% [one of 81]), and pulmonary embolism (1% [one of 81]). With the numbers available, the risk of a complication did not decrease with increasing surgeon experience. After controlling for body mass index and surgeon, the frequency of a complication did not decrease in the experienced interval relative to the initial interval (odds ratio, 0.78; 95% CI, 0.25-2.4; p = 0.6623). The adjusted risk difference between the experienced interval relative and the initial interval was 6% (95% CI, -11% to 23%). When experience was modeled as a continuous variable (number of PAOs performed), increasing experience was not associated with a lower likelihood of a complication (odds ratio per one PAO increase in experience, 0.99; 95% CI, 0.94-1.04; p = 0.5478). However, after adjusting for body mass index and surgeon, increased experience was associated with a reduction in operative time (slope [change in log operative time per one procedure increase in experience], -0.005; 95% CI, -0.009 to -0.0005; p = 0.0292). For every one additional PAO increase in experience, there was a 0.45% decrease in operative time (95% CI, 0.05%-0.86% decrease].
With a case exposure greater than 40 PAOs and progressive surgical responsibility during contemporary structured training, two young surgeons were able to perform PAO with a low risk of complications. However, even with that surgical experience before independent practice, surgical time decreased over the first 40 PAOs they performed independently. Our data may help guide orthopaedic residency and hip preservation fellowship programs in establishing training requirements and assessing competency in PAO.
Level III, therapeutic study.
伯尔尼髋臼周围截骨术（PAO）是一项技术要求高的手术，存在发生严重并发症的潜在风险，且此前报道其学习曲线陡峭。然而，当代髋关节保留专科培训对PAO学习曲线的影响尚未明确。
问题/目的：（1）两位近期从髋关节保留专科培训毕业的外科医生在PAO学习曲线期间严重并发症的发生率是多少？（2）经验水平的提高是否与并发症风险及手术时间相关，手术时间可能是手术操作表现的一个替代指标？
我们回顾性研究了两位近期从髋关节保留专科培训毕业的外科医生在两家机构执业的前4年中所进行的81例PAO手术。其中一位外科医生作为专科培训医生参与了78例PAO手术，在一整年中责任逐渐增加。另一位外科医生在6个月内作为专科培训医生进行了41例PAO手术，在此期间责任也逐渐增加。有68例（84%）女性和13例（16%）男性患者（平均年龄18岁；范围10 - 36岁）。在术后早期及术后1年记录并发症发生频率，并根据一个经过验证的描述并发症五个等级的分类系统进行分级。需要手术干预的并发症（III级）和危及生命的并发症（IV级）被视为严重并发症。术后持续疼痛虽被认为是PAO手术失败，但由于保髋手术后疼痛的多因素病因，不被视为手术并发症。然而，早期再次手术和翻修手术被计为并发症。为评估经验水平提高与并发症发生之间的关联，我们将每位外科医生的经验分为其前20例手术（初始阶段）和后20例手术（经验丰富阶段），以测试两个阶段并发症发生率或手术时间是否不同。由于估计两位外科医生经验与并发症发生可能性之间的关联是一致的，因此分析是基于两位外科医生汇总的数据进行的。为测试初始阶段和经验丰富阶段并发症发生可能性是否存在差异，进行了多因素逻辑回归分析，并计算了两个阶段并发症的调整风险。采用线性回归分析测试外科医生经验水平与手术时间之间的关联。
严重（III级或IV级）并发症的总体发生率为6%（95%置信区间[CI]，2% - 14%）。其中包括深部感染（3%[81例中的3例]）、术中后柱骨折（1%[81例中的1例]）和肺栓塞（1%[81例中的1例]）。就现有数据而言，并发症风险并未随外科医生经验增加而降低。在控制体重指数和外科医生因素后，经验丰富阶段相对于初始阶段并发症发生频率并未降低（优势比，0.78；95% CI，0.25 - 2.4；p = 0.6623）。经验丰富阶段相对于初始阶段的调整风险差异为6%（95% CI， - 11%至23%）。当将经验建模为连续变量（所进行的PAO手术例数）时，经验增加与并发症发生可能性降低无关（经验每增加一例PAO手术的优势比，0.99；95% CI，0.94 - 1.04；p = 0.5478）。然而，在控制体重指数和外科医生因素后，经验增加与手术时间缩短相关（斜率[经验每增加一例手术对数手术时间的变化]， - 0.005；95% CI， - 0.009至 - 0.0005；p = 0.0292）。经验每增加一例PAO手术，手术时间降低0.45%（95% CI，降低0.05% - 0.86%）。
在当代结构化培训中，两位年轻外科医生在进行了超过40例PAO手术且手术责任逐步增加后，能够以较低的并发症风险进行PAO手术。然而，即使在独立执业前有了这样的手术经验，他们在独立进行的前40例PAO手术中手术时间仍有所下降。我们的数据可能有助于指导骨科住院医师培训和髋关节保留专科培训项目制定培训要求并评估PAO手术能力。
III级，治疗性研究。
