Abstract
Purpose of Review
The adaptation of new technology in joint replacement surgery is often associated with a learning curve, as performance tends to improve with experience. The purpose of this review is to define the learning curve and its relevance to joint replacement surgery in the setting of new technological advances, and to draw analogies with the learning curve of basic surgical training.
Recent Findings
Assessing a surgeon’s learning curve for a new technology is complicated and difficult. With every learning curve, the first patients subjected to the novel technology may be at higher risk for adverse events until the learning curve is overcome and a steady state is reached. While measures of performance can be clear and direct in some professions, learning curves with new technology in total joint arthroplasty have been difficult to quantify. Most attempts measure surgical learning curves via an evaluation of the surgical process or patient outcomes. There are published results of both process (i.e., operative time, accuracy of implant position) and outcome measures (i.e., complication rate, revision rate) utilized as proxy for performance during learning curves.
Summary
We review the concept of the learning curve in joint replacement surgery, highlighting examples of learning curves with adaptation of new technologies, and conclude with a discussion of dilemmas and challenges.
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References
Papers of particular interest, published recently, have been highlighted as: • Of importance
Wright TP. Factors affecting the cost of airplanes. J Aeronaut Sci. 1936;3:122–8.
Ramsay CR, Grant AM, Wallace SA, Garthwaite PH, Monk AF, Russell IT. Assessment of the learning curve in health technologies. A systematic review. Int J Technol Assess Health Care. 2000;16:1095–108. https://doi.org/10.1017/s0266462300103149.
Lee Y-K, Moon K-H, Kim J-W, Ha Y-C, Lee M-H, Koo K-H. Learning curve of internal fixation for nondisplaced femoral neck fractures: a cumulative sum analysis. Clin Orthop Surg. 2018;10:9–13. https://doi.org/10.4055/cios.2018.10.1.9.
Nzeako O, Back D. Learning curves in arthroplasty in orthopedic trainees. J Surg Educ. 2016;73:689–93. https://doi.org/10.1016/j.jsurg.2016.02.006.
• Sodhi N, Khlopas A, Piuzzi NS, Sultan AA, Marchand RC, Malkani AL, et al. The learning curve associated with robotic total knee arthroplasty. J Knee Surg. 2018;31:17–21. https://doi.org/10.1055/s-0037-1608809This study assesses robotic-assisted versus manual operative times of 2 arthroplasty surgeons to find a learning curve by time. They demonstrated that within a few months, most board-certified arthroplasty surgeons will be able to adequately perform robotic TKA without the addition of significant operative time.
Coon TM. Integrating robotic technology into the operating room. Am J Orthop. 2009;38:7–9.
• Lakra A, Sarpong NO, Jennings EL, Grosso MJ, Cooper HJ, Shah RP, et al. The learning curve by operative time for soft tissue balancing in total knee arthroplasty using electronic sensor technology. J Arthroplasty. 2019;34:483–7. https://doi.org/10.1016/j.arth.2018.11.014This study quantifies the learning curve by operative time with the use of an electronic sensor technology for soft-tissue balancing during total knee arthroplasty. The authors found that it takes about 41 cases using the technology to achieve operative times identical to manually balanced cases.
Brun O-CL, Månsson L, Nordsletten L. The direct anterior minimal invasive approach in total hip replacement: a prospective departmental study on the learning curve. Hip Int. 2018;28:156–60. https://doi.org/10.5301/hipint.5000542.
Connolly KP, Kamath AF. Direct anterior total hip arthroplasty: comparative outcomes and contemporary results. World J Orthop. 2016;7:94–101. https://doi.org/10.5312/wjo.v7.i2.94.
Ponzio DY, Poultsides LA, Salvatore A, Lee Y-Y, Memtsoudis SG, Alexiades MM. In-hospital morbidity and postoperative revisions after direct anterior vs posterior total hip arthroplasty. J Arthroplasty. 2018;33:1421–1425.e1. https://doi.org/10.1016/j.arth.2017.11.053.
Kamath AF, Chitnis AS, Holy C, Lerner J, Curtin B, Lochow S, et al. Medical resource utilization and costs for total hip arthroplasty: benchmarking an anterior approach technique in the Medicare population. J Med Econ. 2018;21:218–24. https://doi.org/10.1080/13696998.2017.1393428.
Faldini C, Perna F, Mazzotti A, Stefanini N, Panciera A, Geraci G, et al. Direct anterior approach versus posterolateral approach in total hip arthroplasty: effects on early post-operative rehabilitation period. J Biol Regul Homeost Agents. 2017;31:75–81.
Parvizi J, Restrepo C, Maltenfort MG. Total hip arthroplasty performed through direct anterior approach provides superior early outcome: results of a randomized, prospective study. Orthop Clin N Am. 2016;47:497–504. https://doi.org/10.1016/j.ocl.2016.03.003.
Shofoluwe AI, Naveen NB, Inabathula A, Ziemba-Davis M, Meneghini RM, Callaghan JJ, et al. Internet promotion of direct anterior approach total hip arthroplasty by members of the American Association of Hip and Knee Surgeons. J Arthroplasty. 2018;33:167–170.e1. https://doi.org/10.1016/j.arth.2017.08.015.
Müller DA, Zingg PO, Dora C. Anterior minimally invasive approach for total hip replacement: five-year survivorship and learning curve. Hip Int. 2014;24:277–83. https://doi.org/10.5301/hipint.5000108.
den Hartog YM, Vehmeijer SBW. High complication rate in the early experience of minimally invasive total hip arthroplasty by the direct anterior approach. Acta Orthop. 2013;84:116–7. https://doi.org/10.3109/17453674.2013.773412.
de Steiger RN, Lorimer M, Solomon M. What is the learning curve for the anterior approach for total hip arthroplasty? Clin Orthop Relat Res. 2015;473:3860–6. https://doi.org/10.1007/s11999-015-4565-6.
Seng BE, Berend KR, Ajluni AF, Lombardi AV. Anterior-supine minimally invasive total hip arthroplasty: defining the learning curve. Orthop Clin N Am. 2009;40:343–50. https://doi.org/10.1016/j.ocl.2009.01.002.
Schwartz BE, Sisko ZW, Mayekar EM, Wang OJ, Gordon AC. Transitioning to the direct anterior approach in total hip arthroplasty: is it safe in the current health care climate? J Arthroplast. 2016;31:2819–24. https://doi.org/10.1016/j.arth.2016.05.045.
Spaans AJ, van den Hout JAAM, Bolder SBT. High complication rate in the early experience of minimally invasive total hip arthroplasty by the direct anterior approach. Acta Orthop. 2012;83:342–6. https://doi.org/10.3109/17453674.2012.711701.
Sloan M, Premkumar A, Sheth NP. Projected volume of primary total joint arthroplasty in the U.S., 2014 to 2030. J Bone Joint Surg Am. 2018;100:1455–60. https://doi.org/10.2106/JBJS.17.01617.
Bozic KJ, Katz P, Cisternas M, Ono L, Ries MD, Showstack J. Hospital resource utilization for primary and revision total hip arthroplasty. J Bone Joint Surg Am. 2005;87:570–6. https://doi.org/10.2106/JBJS.D.02121.
Culler SD, Jevsevar DS, Shea KG, McGuire KJ, Wright KK, Simon AW. The incremental hospital cost and length-of-stay associated with treating adverse events among Medicare beneficiaries undergoing THA during fiscal year 2013. J Arthroplast. 2016;31:42–8. https://doi.org/10.1016/j.arth.2015.07.037.
Duwelius PJ, Parvizi J, Matsen KL. New technology: safety, efficacy, and learning curves. Clin Orthop Relat Res. 2014;472:1080–5. https://doi.org/10.1007/s11999-013-3413-9.
Gladwell M. Outliers: Penguin; 2009.
• Kayani B, Konan S, Pietrzak JRT, Huq SS, Tahmassebi J, Haddad FS. The learning curve associated with robotic-arm assisted unicompartmental knee arthroplasty: a prospective cohort study. Bone Joint J. 2018;100-B:1033–42. https://doi.org/10.1302/0301-620X.100B8.BJJ-2018-0040.R1This study evaluated the learning curve for robotic-assisted unicompartmental knee arthroplasty (UKA) into routine practice. They reported that it took 6 cases to achieve the learning curve by operative time.
Malchau H, Bragdon CR, Muratoglu OK. The stepwise introduction of innovation into orthopedic surgery: the next level of dilemmas. J Arthroplast. 2011;26:825–31. https://doi.org/10.1016/j.arth.2010.08.007.
Angelos P. The ethics of introducing new surgical technology into clinical practice: the importance of the patient-surgeon relationship. JAMA Surg. 2016;151:405–6. https://doi.org/10.1001/jamasurg.2016.0011.
Pradarelli JC, Thornton JP, Dimick JB. Who is responsible for the safe introduction of new surgical technology?: an important legal precedent from the da Vinci surgical system trials. JAMA Surg. 2017;152:717–8. https://doi.org/10.1001/jamasurg.2017.0841.
Goodman SB, Mihalko WM, Anderson PA, Sale K, Bozic KJ. Introduction of new technologies in orthopaedic surgery. JBJS Rev. 2016;4:1. https://doi.org/10.2106/JBJS.RVW.O.00067.
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Nana Sarpong, Carl Herndon, Michael Held, Alexander Neuwirth, and Thomas Hickernell declare that they have no conflicts of interest.
Jeffrey Geller is a paid consultant for Smith & Nephew and receives research support from OSRF.
H. John Cooper is a paid consultant for DePuy Synthes, KCI, Zimmer-Biomet, OnPoint Knee, and Smith & Nephew.
Roshan Shah is a paid consultant for Link Orthopaedics, unpaid consultant for OnPoint Knee, and receives research support from KCI.
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This work was performed in the Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
This article is part of the Topical Collection on The Use of Technology in Orthopaedic Surgery—Intraoperative and Post-Operative Management
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Sarpong, N.O., Herndon, C.L., Held, M.B. et al. What Is the Learning Curve for New Technologies in Total Joint Arthroplasty? A Review. Curr Rev Musculoskelet Med 13, 675–679 (2020). https://doi.org/10.1007/s12178-020-09671-7
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DOI: https://doi.org/10.1007/s12178-020-09671-7