The Effect of the Learning Curve in Complications for Open Hip Preservation Surgery

The Effect of the Learning Curve in Complications for Open Hip Preservation Surgery Bernardo Aguilera B. MD. Hip preservation bones and join Diseases Institute Imbanaco Medical Center. Cali - Colombia

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Open Hip Preservation Surgery Femoral sub trochanteric osteotomy Femoral neck osteotomy Femoral head osteotomy Periacetabular osteotomy (PAO) Controlled hip dislocation (FAI)

Learning Curve in Open Hip Preservation Surgery There are no exact data about learning curves in open hip surgery except in hip arthroplasty.

Hip arthroplasty THA - minimally invasive incision. Has a significant reduction in the average operation time after the first ten (10) cases. THA anterior mini-invasive approach to reduce the time taken for surgery requires an average of 25 cases. The number of cases does not influence the number of complications in either technique.

Do Complications in Hip Arthroscopy Change With Experience? Presented at the Annual Meeting of the American Academy of Orthopaedic Surgeons, Las Vegas, Nevada, February 2009. Bruno Gonçalves Schröder e Souza, M.D., Wiliam Soltau Dani, M.D., Emerson Kiyoshi Honda, M.D., Ph.D., Walter Ricioli Jr, M.D., Rodrigo Pereira Guimarães, M.D., Nelson Keiske Ono, M.D., Ph.D, Giancarlo Cavalli Polesello, M.D., Ph.D. Department of Orthopedics and Traumatology, Medical Sciences Faculty, Santa Casa de São Paulo, São Paulo, Brazil Received: May 26, 2009; Accepted: December 16, 2009; Published Online: June 07, 2010 Results There were 12 complications (6.1%) in this series. Of these, 5 were neurologic (2.6%), 4 were musculoskeletal (2%), and 3 were vascular/ischemic (1.5%). According to severity, 2 were considered major complications (1%), 8 were intermediate (4.1%), and 2 were minor (1%). \ The incidence of complications did not change with time (P =.959) or with the number of cases performed (P =.771), but different types of complications occurred along the learning curve. Conclusions The nature of complications changed with experience, but no significant variation in the incidence was observed over the 9-year period of experience with hip arthroscopy. Level of Evidence Level IV, therapeutic case series.

Peri-acetabular Osteotomy Trousdale et al. [30] (1995) Crockarell et al. [6] (1999) Matta et al. [17] (1999) Mayo et al. [18] (1999) Siebenrock et al. [27] (1999) Trumble et al. [31] (1999) Sen et al. [26] (2003) Clohisy et al. [3] (2005) Kralj et al. [15] (2005) Cunningham et al. [7] (2006) Peters and Erickson [23] (2006) Biedermann et al. [2] (2008) Clohisy et al. [5] (2007) 6% to 37% of patients experienced a major complication. Periacetabular Osteotomy A Systematic Literature Review John C. Clohisy MD, Amanda L. Schutz PhD, MPA, Lauren St. John BS, Perry L. Schoenecker MD, Rick W. Wright MD Published online: 21 April 2009

Peri-acetabular Osteotomy There is a well-reported learning curve period for PAO, thought to include approximately the first 20 osteotomies during which major surgical complications are not uncommon. and with a structured learning program can change type of complications and improve outcomes Mentoring in complex surgery: minimising the learning curve complications from peri-acetabular osteotomy Donald W. Howie & Martin Beck & Kerry Costi & Susan M. Pannach & Reinhold Ganz

Major complications include deep vein thrombosis, major arterial thrombosis (iliac/femoral), major vessel laceration (iliac/ femoral), pulmonary embolism, symptomatic or clinically important (limitation of hip motion) heterotopic ossification, lateral femoral cutaneous nerve dysfunction requiring surgery, femoral/sciatic nerve dysfunction, intraarticular osteotomies, intraarticular fracture, hematomas and infec- tion requiring surgery, femoral head resubluxation requiring surgery, major blood loss, femoral head and acetabular osteonecrosis, posterior column discontinuity, malreduction requiring revision osteotomy, any nonunion requiring bone grafting, and loss of acetabular fixation requiring reoperation. Moderate complications consisted of: symptomatic hardware (with or without surgical removal), ischial fracture or posterior column fracture not requiring surgery, hematoma with unspecified or nonsurgical treatment, and mildly symptomatic nonunion not requiring surgery. Minor complications included asymptomatic or minimal heterotopic ossification, asymptomatic pubic nonunion, superficial infection not requiring surgery, lateral femoral cutaneous nerve dysfunction or dysesthesias not requiring intervention, and miscellaneous

Major complications femoral/sciatic nerve dysfunction Intra articular fracture major blood loss posterior column discontinuity Mal reduction requiring revision osteotomy major vessel laceration (iliac/ femoral) Deep infection

Controlled hip dislocation (FAI) Major complication -Avascular necrosis -Deep infection -Neuropraxia major complication rates have ranged from 3.3% to 6%, most commonly in the form of trochanteric nonunion, neurapraxia, or heterotopic ossification. HSS J. 2013 Feb;9(1):60-9. doi: 10.1007/s11420-012-9323-7. Epub 2013 Jan 24. Surgical dislocation of the hip: evolving indications. Ross JR, Schoenecker PL, Clohisy JC.

Complication as a measure? The question is. Can we compare the learning curve a surgery has many risks with another who is less risky?

learning curve The learning curve is determined by: -the average operation time. -the number of complications. -clinical outcomes. Why is measuring Learning Curves is so difficult

Measuring the surgical 'learning curve': methods, variables and competency. Khan, Nuzhath. Abboudi, Hamid. Khan, Mohammed Shamim. Dasgupta, Prokar. Ahmed, Kamran. A review of the surgical literature pertaining to LCs was conducted using the Medline and OVID databases. Measuring the surgical LC has potential benefits for patient safety and surgical education. The methods and variables used to measure LC are not standardized Others variables should be controlled, such as: surgeon s prior experience case mix difficulty of procedures and level of supervision

Time-Action Analysis (TAA) of the Surgical Technique Implanting the Collum Femoris Preserving (CFP) Hip Arthroplasty. TAASTIC trial Identifying pitfalls during the learning curve of surgeons participating in a subsequent randomized controlled trial (An observational study) Jakob van Oldenrijk1 *, Matthias U Schafroth1, Mohit Bhandari3, Wouter C Runne2 and Rudolf W Poolman2 * Department of Orthopaedic Surgery, Academic Medical Centre, Amsterdam, The Netherlands 2 Two types of methods are used to assess learning curves: -outcome assessment. -process assessment. Outcome measures are usually dichotomous rare events like complication rates and survival or require an extensive follow-up and are therefore often inadequate to monitor individual learning curves. Time-action analysis (TAA) is a tool to objectively determine the level of efficiency of individual steps of a surgical procedure.

Expected objective EO time = total time - delay Delay: repetition, waiting and further action. Efficiency: the percentage of uptime. It is a representation of the level of difficulty of each procedure for the surgeon. Time-Action Analysis (TAA) of the Surgical Technique Implanting the Collum Femoris Preserving (CFP) Hip Arthroplasty. TAASTIC trial Identifying pitfalls during the learning curve of surgeons participating in a subsequent randomized controlled trial (An observational study) Jakob van Oldenrijk1 *, Matthias U Schafroth1, Mohit Bhandari3, Wouter C Runne2 and Rudolf W Poolman2 * Corresponding author: Jakob van Oldenrijk jakobvanoldenrijk@gmail.com Author Affiliations 1 Department of Orthopaedic Surgery, Academic Medical Centre, Amsterdam, The Netherlands 2 Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands 3 Department of Orthopaedic Surgery, McMaster University, Hamilton, Canada

Depending on the pathology and the type of procedure. The learning curve varies between individual surgeons skills Should evaluate multiple surgeons with different levels of experience. Level of supervision Time-Action Analysis (TAA) of the Surgical Technique Implanting the Collum Femoris Preserving (CFP) Hip Arthroplasty. TAASTIC trial Identifying pitfalls during the learning curve of surgeons participating in a subsequent randomized controlled trial (An observational study) Jakob van Oldenrijk1 *, Matthias U Schafroth1, Mohit Bhandari3, Wouter C Runne2 and Rudolf W Poolman2 *

Overall objective The number of cases required for a surgeon to become proficient with a new procedure. Is directly related to the decline of major complications and get better results

PAO At the Start of the Learning Curve hard Easy

What we need to have a good curve? Knowledge about hip anatomy. Knowledge about hip pathologies. Having a good mentor. See a definite number of surgeries before operating To be able to perform consecutive surgeries to develop their own skills

PAO At the End of the Learning Curve hard Easy

Periacetabular Osteotomy A Systematic Literature Review John C. Clohisy MD, Amanda L. Schutz PhD, MPA, Lauren St. John BS, Perry L. Schoenecker MD, Rick W. Wright MD A majority of the studies discuss the learning curve experiences of individual surgeon(s) without comparing surgeons and determined the potential for a higher complication rates during the surgeon s learning curve experience. This paper shows very well this situation. It was difficult to compare individual surgeons learning curves because there was a lack of standardization in measuring LCs

Mentoring in complex surgery: minimising the learning curve complications from periacetabular osteotomy Donald W. Howie & Martin Beck & Kerry Costi & Susan M. Pannach & Reinhold Ganz The aim of this study was to determine whether a complex surgical procedure such as peri-acetabular osteotomy could be safely learnt by using a program involving mentoring by a distant expert. Mentoring is an important method of learning complex surgery when prolonged exposure and training under direct supervision is not practicable, a not uncommon situation for senior surgeons faced with the challenge of adopting a new surgical procedure. A process of mentoring by a distant, expert surgeon, over more than a decade has allowed a complex surgical procedure to be safely learnt and surgical expertise maintained in remote centres.

In summary Our standard technique is open surgery. Each procedure has its learning curve depending on the degree of difficulty. The impact of the learning curve depends on the initial risk of procedure The position and experience of surgeon to start the learning curve also influence. When a new technique requires new instruments and or new equipment the learning curve is extended as time is needed to learn how to handle. Time-action analysis (TAA) is a tool to objectively determine the level of efficiency of individual steps of a surgical procedure. No is the number of complications, is the type of complications one way to measure the learning curve. It is clear that in open procedures the serious complications change to minor complications with proper learning curves.

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