Trainer vs Trainee: Clinical outcome of primary total ankle replacement. Can learning curve be included during training?

Transcription

1 Trainer vs Trainee: Clinical outcome of primary total ankle replacement. Can learning curve be included during training? Kailash Devalia, FRCS (Tr & Orth) Jayasree Ramaskandhan, BPhT, MPT, MSc Malik Siddique, FRCS (Tr & Orth)

2 Trainer vs Trainee: Clinical outcome of primary total ankle replacement. Can learning curve be included during training? Kailash Devalia My disclosure is in the Final AOFAS Mobile App. I have no potential conflicts with this presentation.

3 AIM Ankle replacement is a technically demanding procedure; has a shallow learning curve with the best results being achieved with the surgeons' experience. The complications appear to be a function of the surgeon s familiarity with the procedure. The learning curve experience can significantly be improved if senior trainees or fellows are given opportunities to perform this procedure during their training. Aim of study is to investigate whether this learning curve could safely be introduced within the training rotation.

4 MATERIALS & METHODS A prospective study of 153 total ankle replacements (TAR) was undertaken in a single centre between January 2008 and February 2012 to investigate whether there is an association between surgical outcome and the grade of the operating surgeon. Hundred and forty nine TARs were available for review In all cases, the three component, uncemented Mobility prostheses were used (DePuy, Mobility TM Total Ankle System). We had two distinct groups comparing the senior surgeon series (110 TAR) against the trainee series (39 TAR). Senior trainees were defined as year five and year six trainees in final two years of their training rotation The primary outcome measure was the change in the AOFAS scores ( AOFAS).. Secondary outcomes included the rate of revision and length of hospital stay.

5 Results All the scores improved at one year in both the groups including AOFAS, WOMAC, SF-36 and satisfaction scores. No significant difference was noticed in ΔAOFAS (change in AOFAS scores) (p=0.176), length of stay (p=0.08) or complication rates (p=0.076) between the two groups. The incidence of intra-operative fractures was higher in trainee group (4/39; 10.25%) compared to senior surgeon series (2/110; 1.85%). There were five revisions in trainee series, two for deep infection, two for instability and one for aseptic loosening. This was significantly higher (12.8%, p=0.005) compared to senior surgeon series (1.8%). No malalignment of components was seen in any of the groups.

6 Demographics Senior surgeon series Trainee series P Value Number (n) Gender (M/F) 71/39 22/17 Pre operative BMI Average F/U in months 45.4 (18-68) 38.8 (18-67) Average LOS in days 7.45 (2-35) 7.03 (2-14) 0.08 Average ROM degrees Diagnosis PTOA 40 (36.4 %) 17 (43.6 %) RA 10 (9.1 %) 2 (5.1 %) OA 59 (53.6 %) 19 (48.7 %) NM 1 (0.9%) 1 (2.6%)

7 AOFAS Senior surgeon Trainees P Value AOFAS Pre op (n=87) (n=28) One year (n=57) (n=19) AOFAS Three years (n=34) (n=6) AOFAS

8 WOMAC Senior surgeon Trainees P Value Pain Pre op (n=79) 38.5 (n=29) One year (n=47) (n=19) WP Three years (n=38) (n=7) WP Stiffness Pre op (n=80) (n=26) One year (n=55) (n=19) WS Three years (n=44) (n=9) WS Function Pre op (n=79) (n=26) One year (n=54) (n=19) WF Three years (n=43) (n=9) 0.576

9 Details of cases requiring revision surgery or arthrodesis Case Surgeon Diagnosis Pre operative deformity 1 SS OA Varus 16 degrees Duration between index and revision surgery in months Reason for revision 19 Varus instability 2 SS OA None 58 Varus instability 3 T OA None 17.5 Aseptic loosening 4 T OA Varus 28 degrees 20.5 Varus instability 5 T RA None 8.5 Deep infection 6 T PTOA None 9.5 Deep infection 7 T OA None 4 Lateral instability Final outcome Cemented revision Cemented revision Cemented revision Revision TAR Ankle arthrodesis Two stage revision Ankle arthrodesis

10 Complications in two groups Complications Total SS Trainees P value Minor complications Minor wound problems 20 (13.6%) 16 (14.5%) 4 (10.25%) Fractures Intra op 6 (4.08%) 2 (1.85%) 4 (10.25%) Stress Fractures Post op 12 (8.1%) 10 (9.1%) 2 (5.1%) Pain 24 (16.1%) 17 (15.5%) 7 (17.9%) CRPS 5 (3.4%) 4 (3.6%) 1 (2.6%) Minor wound problems 20 (13.6%) 16 (14.5%) 4 (10.25%) Major complications DVT/PE Deep infection 2 (1.3%) 0 2 (5.12%) Tendon/Nerve injury 1 (0.7%) 0 1 (2.6%) Talar subsidence 2 (1.3%) 1 (0.9%) 1 (2.6%) Revision 7 (4.08%) 2 (1.8 %) 5 (12.8 %) 0.005

11 Conclusion The outcome observed in our trainee series is comparable to the published results of TAR during the surgeon s initial learning curve. The study provides the evidence that ankle replacements can safely be performed by appropriately trained surgeons in training. A closed senior supervision is vital during the initial learning curve to improve surgical technique and the outcome. The trainees however should not be allowed to perform complex ankle replacements until they are experienced to reduce the revision rate.

12 References Roukis TS, Prissel MA. Registry data trends of total ankle replacement use. J Foot Ankle Surg Nov-Dec;52(6): doi: /j.jfas Myerson, M.S., Mroczek, K. Perioperative complications of total ankle arthroplasty. Foot and Ankle International Volume 24, Issue 1, 1 January 2003, Pages Haskell, A.a, Mann, R.A.bc. Perioperative complication rate of total ankle replacement is reduced by surgeon experience (Review). Foot and Ankle International Volume 25, Issue 5, May 2004, Pages Lee KB, Cho SG, Hur CI, Yoon TR. Perioperative complications of HINTEGRA total ankle replacement: our initial 50 cases. Foot Ankle Int 29: , Schuberth JM, Patel S, Zarutsky E. Perioperative complications of the Agility total ankle replacement in 50 initial, consecutive cases. J Foot Ankle Surg 45: , Arun Kumar, Sunil Dhar. Total ankle Replacement: Early results during learning period. Foot and Ankle Surgery, Volume 13,Issue 1,2007, Pages Bleazey ST, Brigido SA, Protzman NM. Perioperative complications of a modular stem fixed-bearing total ankle replacement with intramedullary guidance. J Foot Ankle Surg Jan-Feb;52(1): doi: /j.jfas Epub 2012 Nov 13. Lee KT, Lee YK, Young KW, Kim JB, Seo YS. Perioperative complications and learning curve of the Mobility Total Ankle System. Foot Ankle Int Feb;34(2): doi: / Epub 2013 Jan 11. Renwick AA, Bokey EL, Chapuis PH, et al. Effect of supervised surgical training on outcomes after resection of colorectal cancer. Br J Surg 2005;92: Martin L, Delbridge L, Martin J, et al. Trainee surgery in teaching hospitals: is there a cost? Aust N Z J Surg 1989;59: Hutter MM, Glasgow RE, Mulvihill SJ. Does the participation of a surgical trainee adversely impact patient outcomes?: a study of major pancreatic resections in California. Surgery 2000;128: Maslekar S, Sharma A, Macdonald A, et al. Do supervised colorectal trainees differ from consultants in terms of quality of TME surgery? Colorectal Dis 2006;8:790-4.