Avendano John P, Sudah Suleiman Y, Gencarelli Pasquale, Imam Nareena, Manzi Joseph E, Ghajar Mina, Menendez Mariano E, Nicholson Allen D
Department of Orthopedics, Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
Department of Orthopedics, Monmouth Medical Center, Long Branch, NJ, USA.
JSES Rev Rep Tech. 2022 Dec 27;3(2):150-159. doi: 10.1016/j.xrrt.2022.12.001. eCollection 2023 May.
Despite the rising incidence of anatomic total shoulder arthroplasty (ATSA) and reverse total shoulder arthroplasty (RTSA) among surgeons, little is known about the learning curve associated with these procedures. The purpose of this systematic review was to (1) identify the learning curves associated with ATSA and RTSA, (2) evaluate the effect of the learning curves on clinical outcomes, and (3) determine the number of cases needed to achieve proficiency.
Four online databases [PubMed (NLM), MEDLINE (OVID), Cochrane Library (Wiley), and Scopus (Elsevier)] were systematically searched and screened according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The search included results from the inception of each database to May 18, 2022. Data regarding study characteristics, patient demographics, learning curve analyses, patient reported outcome measures, range of motion, complication rates, and reoperation rates were collected. A quality assessment for each article was performed according to the Methodological Index for Nonrandomized Studies criteria.
A total of 13 studies of fair to good quality were included for analysis (one of level II evidence, five of level III, and seven of level IV) with the majority originating from the United States [n = 8, 61.5%]. Overall, there were a total of 3381 cases (1861 RTSA and 1520 ATSA), with a mean patient age of 72.6 years [range: 45-92 years]. From the studies analyzed in this systematic review, for RTSA, the approximate average number of cases surgeons need to perform to move to an acceptable position on the RTSA learning curve is 25 cases. For ATSA, a wider range of 16-86 cases was derived as only two studies reported on ATSA.
Progression along the learning curve for RTSA and ATSA results in decreased operative times, improved patient-reported outcomes, and fewer complications. However, a true learning curve is difficult to quantify given the heterogeneity of reported outcome measures, individual surgeon experience at the time of data collection, and statistical analyses used across studies.
尽管解剖型全肩关节置换术（ATSA）和反式全肩关节置换术（RTSA）在外科医生中的发病率不断上升，但对于这些手术相关的学习曲线却知之甚少。本系统评价的目的是：（1）确定与ATSA和RTSA相关的学习曲线；（2）评估学习曲线对临床结果的影响；（3）确定达到熟练程度所需的病例数。
根据系统评价和Meta分析的首选报告项目指南，对四个在线数据库[PubMed（NLM）、MEDLINE（OVID）、Cochrane图书馆（Wiley）和Scopus（Elsevier）]进行系统检索和筛选。检索范围包括每个数据库创建之初至2022年5月18日的结果。收集有关研究特征、患者人口统计学、学习曲线分析、患者报告的结局指标、活动范围、并发症发生率和再次手术率的数据。根据非随机研究方法学指数标准对每篇文章进行质量评估。
共纳入13项质量中等至良好的研究进行分析（二级证据1项，三级证据5项，四级证据7项），其中大部分来自美国[n = 8，61.5%]。总体而言，共有3381例病例（1861例RTSA和1520例ATSA），患者平均年龄为72.6岁[范围：45 - 92岁]。从本系统评价分析的研究来看，对于RTSA，外科医生要在RTSA学习曲线上达到可接受水平，大约平均需要进行25例手术。对于ATSA，由于仅有两项研究报告了ATSA，得出的范围较宽，为16 - 86例。
沿着RTSA和ATSA的学习曲线进展会导致手术时间缩短、患者报告的结局改善以及并发症减少。然而，鉴于报告的结局指标的异质性、数据收集时个体外科医生的经验以及各研究使用的统计分析方法，真正的学习曲线难以量化。
