Fellow Involvement in Primary Total Knee Arthroplasty: Is There an “August Effect?”

Abstract

The purpose of this study is to determine if a fellow's involvement, as well as duration of a fellow's training, impacts complications, outcomes, and survivorship in primary total knee arthroplasty (TKA). A retrospective review identified 2,790 consecutive patients (3,530 knees) who underwent primary TKA between 2003 and 2008. A 2-year minimum follow-up was available on 2,785 knees (2,195 patients). Operative data, clinical outcomes, complications, and survivorship were compared between cases with and without a fellow involved as well as comparing cases in the first quarter (Q1) of the academic year to the last three quarters (Q2–4). Mean follow-up was 9.7 years. Fellows were involved in 1,434 (41%) surgeries. Fellow cases had significantly longer tourniquet times (59.5 vs. 49 minutes, p < 0.001) and operative times (82.4 vs. 70.8 minutes, p < 0.001). Overall, there was no difference in clinical, functional, or pain outcomes between attending and fellow cases. Fellow cases during Q1 had significantly worse pain scores (p = 0.009) and clinical scores (p < 0.001). Revision rate, infection rates, and survivorship were not significantly different between fellow and attendings or during Q1 of fellowship compared with attendings. Primary TKA survivorship and complications were not affected by fellow involvement or academic quarter. An “August Effect” may be suggested for clinical and pain outcomes in the first 3 months of fellowship.

Keywords

fellow - trainee - knee - arthroplasty - survivorship

Publikationsverlauf

Eingereicht: 11. September 2019

Angenommen: 02. Mai 2020

Artikel online veröffentlicht:
19. Juni 2020

• References

• 1 Homma S, Kawamata F, Yoshida T. et al. The balance between surgical resident education and patient safety in laparoscopic colorectal surgery: surgical resident's performance has no negative impact. Surg Laparosc Endosc Percutan Tech 2017; 27 (04) 295-300
• 2 Gorelik M, Godelman S, Elkbuli A, Allen L, Boneva D, McKenney M. Can residents be trained and safety maintained?. J Surg Educ 2018; 75 (01) 1-6
• 3 Brown T. . Don't get sick in July. New York Times; 2012. Accessed July 14, 2012 at: https://opinionator.blogs.nytimes.com/2012/07/14/dont-get-sick-in-july/
• 4 Englesbe MJ, Pelletier SJ, Magee JC. et al. Seasonal variation in surgical outcomes as measured by the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP). Ann Surg 2007; 246 (03) 456-462 , discussion 463–465
• 5 Ehlert BA, Nelson JT, Goettler CE. et al. Examining the myth of the “July Phenomenon” in surgical patients. Surgery 2011; 150 (02) 332-338
• 6 Blough JT, Jordan SW, De Oliveira Jr GS, Vu MM, Kim JYS. Demystifying the “July Effect” in plastic surgery: a multi-institutional study. Aesthet Surg J 2018; 38 (02) 212-224
• 7 Zuk K, Jensen D, Gills J. et al. The July Effect in radical cystectomy: mortality, morbidity, and efficiency. Bladder Cancer 2016; 2 (04) 433-439
• 8 Saqib A, Ibrahim U, Patel P, Joshi A, Chalhoub M. Mortality among high-risk patients admitted with septic shock to U.S. teaching hospitals in July: does the ‘July Effect’ exist?. Heart Lung 2017; 46 (02) 110-113
• 9 Varma S, Mehta A, Hutfless S, Stone RL, Wethington SL, Fader AN. Is there evidence of a July effect among patients undergoing hysterectomy surgery?. Am J Obstet Gynecol 2018; 219 (02) 176.e1-176.e9
• 10 Lieber BA, Appelboom G, Taylor BE, Malone H, Agarwal N, Connolly Jr ES. Assessment of the “July Effect”: outcomes after early resident transition in adult neurosurgery. J Neurosurg 2016; 125 (01) 213-221
• 11 Bohl DD, Fu MC, Golinvaux NS, Basques BA, Gruskay JA, Grauer JN. The “July effect” in primary total hip and knee arthroplasty: analysis of 21,434 cases from the ACS-NSQIP database. J Arthroplasty 2014; 29 (07) 1332-1338
• 12 Aynardi M, Miller AG, Orozco F, Ong A. Effect of work-hour restrictions and resident turnover in orthopedic trauma. Orthopedics 2012; 35 (11) e1649-e1654
• 13 Woolson ST, Kang MN. A comparison of the results of total hip and knee arthroplasty performed on a teaching service or a private practice service. J Bone Joint Surg Am 2007; 89 (03) 601-607
• 14 Weber M, Worlicek M, Voellner F. et al. Surgical training does not affect operative time and outcome in total knee arthroplasty. PLoS ONE 2018; 13 (06) e0197850
• 15 Anderson KL, Koval KJ, Spratt KF. Hip fracture outcome: is there a “July effect”?. Am J Orthop 2009; 38 (12) 606-611
• 16 Horst PK, Choo K, Bharucha N, Vail TP. Graduates of orthopaedic residency training are increasingly subspecialized: a review of the american board of orthopaedic surgery part II database. J Bone Joint Surg Am 2015; 97 (10) 869-875
• 17 Aminian A, Chaudhry RM, Khorgami Z. et al. A challenge between trainee education and patient safety: does fellow participation impact postoperative outcomes following bariatric surgery?. Obes Surg 2016; 26 (09) 1999-2005
• 18 Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the knee society clinical rating system. Clin Orthop Relat Res 1989; (248) 13-14
• 19 Pour AE, Bradbury TL, Horst P, Harrast JJ, Erens GA, Roberson JR. Trends in primary and revision knee arthroplasty among orthopaedic surgeons who take the American Board of Orthopaedics part II exam. Int Orthop 2016; 40 (10) 2061-2067
• 20 Lee WC, Kwan YH, Chong HC, Yeo SJ. The minimal clinically important difference for Knee Society Clinical Rating System after total knee arthroplasty for primary osteoarthritis. Knee Surg Sports Traumatol Arthrosc 2017; 25 (11) 3354-3359
• 21 Lavernia CJ, Sierra RJ, Hernandez RA. The cost of teaching total knee arthroplasty surgery to orthopaedic surgery residents. Clin Orthop Relat Res 2000; (380) 99-107
• 22 Vinden C, Malthaner R, McGee J. et al. Teaching surgery takes time: the impact of surgical education on time in the operating room. Can J Surg 2016; 59 (02) 87-92
• 23 Naranje S, Lendway L, Mehle S, Gioe TJ. Does operative time affect infection rate in primary total knee arthroplasty?. Clin Orthop Relat Res 2015; 473 (01) 64-69
• 24 Duchman KR, Pugely AJ, Martin CT, Gao Y, Bedard NA, Callaghan JJ. Operative time affects short-term complications in total joint arthroplasty. J Arthroplasty 2017; 32 (04) 1285-1291
• 25 Anis HK, Sodhi N, Klika AK. et al. Is operative time a predictor for post-operative infection in primary total knee arthroplasty?. J Arthroplasty 2019; 34 (7S): S331-S336