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      What Is the Learning Curve for the Anterior Approach for Total Hip Arthroplasty?

      research-article
      , MBBS, FRACS 1 , , , BSc(Math & Comp Sci) (Hons) 2 , , MBChB, FRACS 3
      Clinical Orthopaedics and Related Research
      Springer US

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          Abstract

          Background

          There are many factors that may affect the learning curve for total hip arthroplasty (THA) and surgical approach is one of these. There has been renewed interest in the direct anterior approach for THA with variable outcomes reported, but few studies have documented a surgeon’s individual learning curve when using this approach.

          Questions/purposes

          (1) What was the revision rate for all surgeons adopting the anterior approach for placement of a particular implant? (2) What was the revision rate for surgeons who performed > 100 cases in this fashion? (3) Is there a minimum number of cases required to complete a learning curve for this procedure?

          Methods

          The Australian Orthopaedic Association National Joint Replacement Registry prospectively collects data on all primary and revision joint arthroplasty surgery. We analyzed all conventional THAs performed up to December 31, 2013, with a primary diagnosis of osteoarthritis using a specific implant combination and secondarily those associated with surgeons performing more than 100 procedures. Ninety-five percent of these procedures were performed through the direct anterior approach. Procedures using this combination were ordered from earliest (first procedure date) to latest (last procedure date) for each individual surgeon. Using the order number for each surgeon, five operation groups were defined: one to 15 operations, 16 to 30 operations, 31 to 50 operations, 51 to 100 operations, and > 100 operations. The primary outcome measure was time to first revision using Kaplan-Meier estimates of survivorship.

          Results

          Sixty-eight surgeons performed 5499 THAs using the specified implant combination. The cumulative percent revision at 4 years for all 68 surgeons was 3% (95% confidence interval [CI], 2.5–3.8). For surgeons who had performed over 100 operations, the cumulative revision rate was 3% (95% CI, 2.0–3.5). It was not until surgeons had performed over 50 operations that there was no difference in the cumulative percent revision compared with over 100 operations. The cumulative percent revision for surgeons performing 51 to 100 operations at 4 years was 3% (95% CI, 1.5–5.4) and over 100 operations 2% (95% CI, 1.2–2.7; hazard ratio, 1.40 [95% CI, 0.7–2.7]; p = 0.33).

          Conclusions

          There is a learning curve for the anterior approach for THA even when using a prosthesis combination specifically marketed for that approach. We found that 50 or more procedures need to be performed by a surgeon before the rate of revision is no different from performing 100 or more procedures. Surgeons should be aware of this initial higher rate of revision when deciding which approach delivers the best outcome for their patients.

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          Author and article information

          Contributors
          richard.desteiger@epworth.org.au
          Journal
          Clin Orthop Relat Res
          Clin. Orthop. Relat. Res
          Clinical Orthopaedics and Related Research
          Springer US (New York )
          0009-921X
          1528-1132
          22 September 2015
          December 2015
          : 473
          : 12
          : 3860-3866
          Affiliations
          [1 ]grid.1008.9000000012179088XDepartment of Surgery, Epworth Healthcare, University of Melbourne, AOA National Joint Replacement Registry, Hoddle Street, Richmond, VIC 3121 Australia
          [2 ]grid.1010.00000000419367304Data Management and Analysis Centre, Discipline of Public Health, University of Adelaide, Adelaide, Australia
          [3 ]grid.1005.40000000449020432Prince of Wales Hospital, The University of New South Wales, Sydney, Australia
          Article
          PMC4626490 PMC4626490 4626490 4565
          10.1007/s11999-015-4565-6
          4626490
          26394641
          89d83828-b660-4370-939e-df21b2685feb
          © The Association of Bone and Joint Surgeons® 2015
          History
          Categories
          Symposium: 2014 International Hip Society Proceedings
          Custom metadata
          © The Association of Bone and Joint Surgeons® 2015

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