Perioperative Differences Between Outpatient and Inpatient Pathways Following Hip and Knee Arthroplasty.

Background: Optimization of clinical pathways and logistics led to the introduction of outpatient joint arthroplasty of the hip and knee. Nevertheless, little is known about what these current protocols look like and how they differ from "standard" inpatient protocols. This study aimed to find preoperative, intraoperative, and postoperative differences between outpatient and inpatient pathways. Methods: A questionnaire (ranging between 23 and 37 items) was developed and administered by email to orthopedic surgeons who were a member of the Dutch Hip Society and Dutch Knee Society. Survey response rate was 38% (N = 117). Results: No significant differences were found in preoperative pathway characteristics. The administration regime for tranexamic acid significantly differed between outpatient and inpatient pathways (P < .001 and P = .002 for hip and knee arthroplasty, respectively), with outpatient pathways using a combined (eg, oral and intravenous) administration regime more frequently. The perioperative antibiotic prophylaxis regime also significantly differed between outpatient and inpatient pathways (P < .001 and P = .014, respectively), with outpatient pathways more frequently incorporating fewer antibiotic doses. Same-day postoperative mobilization significantly less often occurred if surgery took place later that day in inpatient hip arthroplasty pathways (24%; P = .034). Postoperative hemoglobin-check occurred significantly more often on indication in outpatient than in inpatient hip and knee arthroplasty pathways (∼75% vs ∼25%; P = .001). Conclusions: Few intraoperative and postoperative differences in outpatient and inpatient pathways were found and probably mainly relied on logistical grounds. Nonetheless, findings suggested that outpatient pathways tended to be more up-to-date and innovative than inpatient pathways.

Survival rates of anatomically shaped and tapered slip cemented femoral implants: an analysis of 76,281 femoral implants of the Dutch arthroplasty register (LROI).

INTRODUCTION: In cemented total hip arthroplasty (THA) various shapes and geometries of femoral implants are in use. Collarless, polished, and tapered (CPT) implants, and anatomically shaped (AS) implants are most commonly used. Due to their different design features, this might lead to different survival outcomes. In this register-based study, overall implant survival and short-term complications of CPT and AS cemented implants were evaluated. METHODS: Data of the Dutch Arthroplasty Register (LROI) were used. Cemented femoral implants, which could be classified as CPT or AS were included in this study. Implants were excluded when no classification could be made or if implanted <100 times. Survival analyses were performed using Kaplan-Meier survival analysis and multivariable Cox-proportional hazard analysis. RESULTS: 76,281 cemented THAs were included. At a mean of 5.1 years follow-up (SD 3.1, range 0-12 years), the overall survival of the AS implants was higher compared with the CPT implants, with a survival, of 99.2% and 99.0% respectively (log-rank; p < 0.001). Multivariable regression analysis revealed a higher rate for revision because of loosening of the AS implants (HR 2; CI, 1.4-3.1). AS implants had a lower rate for periprosthetic fractures compared with the CPT implants (HR 0.13; CI, 0.07-0.23). CONCLUSIONS: Both designs show excellent overall survival rates at short-term follow-up. There is a higher overall survival of AS implants when compared with CPT implants. Revision for implant loosening, however, was statistically significantly higher in AS implants when compared with the CPT implants.

Age-Associated Changes in Proximal Femur Morphology Affect Femoral Component Sizing in Cementless Hip Arthroplasty.

Background: In cementless hip arthroplasty, the femoral component should obtain firm fixation within the endosteal bone and achieve adequate reconstruction of hip joint biomechanics simultaneously. Previous anatomical studies described age-related changes of the proximal femoral canal, such as canal widening, which theoretically necessitates the use of larger stem sizes in elderly patients. This study examines a potential association between patients' age at surgery and the implant size of a cementless femoral component. Material and methods: A total of 13,423 primary hip arthroplasties with a single cementless stem registered in the Dutch Arthroplasty Register (LROI) were included. Patient characteristics (ie patients' age, sex, height and weight at time of surgery) and femoral component size were derived. A one-way ANCOVA was used to compare the mean stem size between age groups, and multivariable linear regression analysis was used in order to investigate to which extent ageing impacted stem size. Results: Each subsequent age- group (ten-year intervals) had a significantly larger mean stem size than the prior age- group. Multivariable linear regression analysis revealed that age is positively correlated with stem size and that this correlation is more prominent in females than in males (beta = .046, P < .001 and beta = .028, P < .001 respectively). Interpretation: Implant size is positively correlated with age, in particular in females and independently from investigated anthropometric characteristics. The present study endorses that the femoral canal morphology is related to patients' characteristics such as age and sex. The morphology will subsequently influence implant sizing and therefore may have biomechanical and clinical implications.

Orthopaedic surgeons' perspective on the implementation of outpatient hip and knee arthroplasty - Results of a nationwide survey.

Background: Outpatient joint arthroplasty (OJA) for the hip and knee is gaining popularity among orthopaedic surgeons worldwide. The purposes of this study were to (1) assess the proportion of Dutch orthopaedic surgeons who perform OJA; (2) identify surgeons' willingness to implement OJA in the future; (3) identify reasons and barriers to implement OJA; and (4) gather surgeon's perspective on the implementation of OJA. Methods: A 20-item survey was developed and administered by email to orthopaedic surgeons who are a member of the Dutch Hip Society and Dutch Knee Society. Survey response rate was 40% (N = 123). Results: Twenty-two respondents (18%) already implemented OJA, and 46% of respondents (who don't perform OJA) were interested to implement OJA in the future. Reasons to perform OJA included own positive experiences (82%), available evidence (77%) and patients' request (77%). Proponents' and opponents' view on safety and added value conflicted with each other. Other barriers included patient selection and organizational related (e.g., multidisciplinary support). Surgeons' view on evolution and relevance of OJA significantly differed by respondents who perform OJA versus respondents who don't perform OJA. Most respondents agreed with one another that the healthcare institution benefits most from OJA, and that optimization of the arthroplasty pathway could be reached through better patient education and -participation (e.g., eHealth, wearables). Conclusion: One in five respondents currently implement OJA pathways, and about half of the remaining respondents are interested to implement OJA in the future. OJA-opponents aren't convinced of the value and safety of OJA, despite accumulating evidence supporting OJA. Future research should inform patient-selection and -acceptance and organizational implementation.

Disappointing evaluation of a shared decision-making intervention for residents and orthopaedic surgeons.

OBJECTIVE: To evaluate a shared decision-making (SDM) intervention in orthopaedic hip and knee osteoarthritis care. METHODS: Using a pre- post intervention design study, we tested an intervention, that included a decision aid for patients (ptDA) and a SDM training course for residents in training and orthopaedic surgeons. The theory of planned behaviour was used for intervention development. Primary outcomes included patient reported decisional conflict, SDM, and satisfaction. Secondary outcomes were physicians' attitude and knowledge, and uptake of the ptDA. RESULTS: 317 patients were included. The intervention improved physicians' knowledge about SDM but had no effect on the primary outcomes. 19 eligible patients used the ptDA (17%). SDM was higher for middle educated patients compared to lower educated (mean difference 9.91, p=0.004), patients who saw surgeons instead of residents (mean difference 5.46, p=0.044) and when surgery was chosen and desired by patients compared to situations where surgery was desired but not chosen (mean difference 15.39, p=0.036). CONCLUSION: Our multifaceted intervention did not improve SDM and ptDA uptake was low. PRACTICE IMPLICATIONS: In orthopaedic hip and knee osteoarthritic care other ways should be explored to successful implement SDM. Since residents received lower SDM scores, special focus should go to this group.

Implicit gender-career bias in postgraduate medical training still exists, mainly in residents and in females.

BACKGROUND: More and more female residents enter postgraduate medical training (PGMT). Meanwhile, women are still underrepresented in academic medicine, in leadership positions and in most surgical specialties. This suggests that female residents' career development may still be negatively impacted by subtle, often unconscious stereotype associations regarding gender and career-ambition, called implicit gender-career bias. This study explored the existence and strength of implicit gender-career bias in doctors who currently work in PGMT, i.e. in attending physicians who act as clinical trainers and in their residents. METHODS: We tested implicit gender-career bias in doctors working in PGMT by means of an online questionnaire and an online Implicit Association Test (IAT). We used standard IAT analysis to calculate participants' IAT D scores, which indicate the direction and strength of bias. Linear regression analyses were used to test whether the strength of bias was related to gender, position (resident or clinical trainer) or specialty (non-surgical or surgical specialty). RESULTS: The mean IAT D score among 403 participants significantly differed from zero (D-score = 0.36 (SD = 0.39), indicating bias associating male with career and female with family. Stronger gender-career bias was found in women (ßfemale =0 .11; CI 0.02; 0.19; p = 0.01) and in residents (ßresident 0.12; CI 0.01; 0.23; p = 0.03). CONCLUSIONS: This study may provide a solid basis for explicitly addressing implicit gender-career bias in PGMT. The general understanding in the medical field is that gender bias is strongest among male doctors' in male-dominated surgical specialties. Contrary to this view, this study demonstrated that the strongest bias is held by females themselves and by residents, independently of their specialty. Apparently, the influx of female doctors in the medical field has not yet reduced implicit gender-career bias in the next generation of doctors, i.e. in today's residents, and in females.

Rates and Causes of 90-day Complications and Readmissions Following Outpatient Hip and Knee Arthroplasty: A Retrospective Analysis of 525 Patients in a Single Institution.

BACKGROUND: Outpatient joint arthroplasty (OJA) has gained increasing popularity and success in a well-defined population. Safety concerns, in terms of complications and readmissions, however still exist. PATIENTS AND METHODS: This retrospective study included 525 patients (90 primary THAs, 277 primary TKAs, and 158 primary UKAs), initially planned for OJA. All complications and readmissions were evaluated for timing and cause (surgical vs medical) within a 90-day followup. Complications and readmissions were compared by the length of stay (LOS): same-day discharge (SDD) vs ≥1 day. Differences were assessed by the log-rank test. Complications and readmission risk were assessed using multivariable logistic regression analysis. RESULTS: The complication rate was 9.9% at 30 days and 15% at 90 days. The readmission rate was 2.5% at 30 days and 4.2% at 90 days. The majority of surgical complications and readmissions were the result of wound discharge (43% and 56%, respectively). Overall, we did not observe different rates between SDD and LOS ≥1. Following THA, but not TKA or UKA, the 90-day complication rate was significantly lower in patients that underwent SDD compared with LOS ≥1. The risk of complications was positively associated with TKA (vs THA and UKA), ASA III (vs ASA I), and Charnley C (vs Charnley A). The risk of readmissions was negatively associated with a BMI ranging from 25-29.9 kg/m2 (vs BMI <25 kg/m2). CONCLUSION: SDD following OJA did not result in more complications and hospital readmissions compared to a prolonged hospital stay. The majority of complications and readmissions were due to noninfected wound discharge.

Patients with hip resurfacing arthroplasty are not physically more active than those with a stemmed total hip.

Background and purpose - Hip resurfacing arthroplasty (HRA) was designed for the highly active patient because of the various theoretical advantages compared with stemmed total hip arthroplasty (THA), but has shown high failure rates. Physical activity (PA) after arthroplasty is frequently determined with the use of questionnaires, which are known for their subjective nature, recall bias, and ceiling effect. These disadvantages are not applicable to physical activity monitoring (AM) using sensors. We compared objectively measured PA at long-term follow-up in a matched cohort of HRA and stemmed THA subjects.Patients and methods - We compared 2 groups of 16 patients (12 males) in each group, one having received unilateral HRA (median age 56 years at surgery) and a matched group having received unilateral stemmed THA with a small diameter femoral head (28 mm) on conventional polyethylene (median age 60 years at surgery) with osteoarthritis as indication for surgery, 10 years after surgery. Groups were matched by sex, age at surgery, and BMI. The daily habitual PA was measured over 4 consecutive days in daily living using a 3-axis accelerometer, gyroscope, and magnetometer. Both quantitative parameters (time standing, sitting, walking, number of steps, and sit-stand transfers) and qualitative parameters (walking cadence) were determined.Results - The AM was worn for a median 13 (11-16) hours per day. The median daily step count was 5,546 (2,274-9,966) for the HRA group and 4,583 (1,567-11,749) for the stemmed THA-group with 39 (21-74) versus 37 (24-62) daily sit-stand transfers respectively. The other PA parameters were also similar in both groups.Interpretation - We found similar median PA levels and also identical ranges. While short-term effects may exist, ageing and related behavioral adaptations or other effects seem to render the theoretical activity benefits from HRA irrelevant at longer follow-up.

Quality, but not quantity of physical activity is associated with metal ion concentrations in unilateral hip resurfacing.

Little is known about the influence of physical activity (PA) on metal ion concentrations in subjects with metal-on-metal hip arthroplasty. Implant wear is thought to be a function of use and thus of patient activity levels. It is hypothesized that daily habitual PA of patients with hip resurfacing arthroplasty (HRA) is associated with metal ion concentrations. Therefore a study was conducted in patients with a unilateral HRA at 10-years follow-up. Blood metal ion concentrations were determined. An acceleration-based activity monitor was used to measure PA in daily life. The cohort consisted of 12 males (75%) and 4 females (25%) with a median age at surgery of 55.5 ± 9.7 years [43.0-67.9] and a median follow-up of 9.9 ± 1.0 years [9.1-10.9]. The median cobalt and chromium ion concentrations were 25 ± 13 and 38 ± 28 nmol/L. A significant association between sit-stand transfers and high-intensity peaks with cobalt ion concentrations were found. Regarding PA and metal ion concentrations as a proxy of wear in HRA, specific activities like transfers or qualitative aspects of activity behavior like intensity, seem to matter more than the quantity of low-intensity activities like walking or cycling. This suggests that patients may safely engage in such activities to achieve important general health benefits and quality of life.

The association of leg length and offset reconstruction after total hip arthroplasty with clinical outcomes.

BACKGROUND: Restoring native hip anatomy and biomechanics is important to create a well-functioning hip arthroplasty. This study investigated the association of hip offset and leg length after hip arthroplasty with clinical outcomes, including patient reported outcome measures, the Trendelenburg Test and gait analysis. METHODS: In 77 patients undergoing primary hip arthroplasty for osteoarthritis (age mean = 65 SD = 11 years; BMI mean = 27 SD = 5 kg/m2), hip offset and leg length discrepancy were measured on anteroposterior radiographs. The Western Ontario & McMaster Universities Osteoarthritis Index, the Trendelenburg Test and gait were assessed preoperatively, and at 3 and 12 months postoperatively. An inertial measurement unit was used to derive biomechanical parameters, including spatiotemporal gait parameters and tilt angles of the pelvis. Relationships between radiographic and functional outcomes were investigated, and subgroups of patients with >15% decreased and increased femoral offset were analysed separately. FINDINGS: Patient-reported function scores and clinical tests demonstrated a few significant, weak correlations with radiographic outcomes (Spearman's ρ range = 0.26-0.32; p < 0.05). Undercorrection of femoral offset was associated with lower patient-reported function scores and with more step irregularity as well as step asymmetry during gait. Postoperative leg length inequality was associated with increased frontal plane tilt angle of the pelvis during the Trendelenburg Test and increased sagittal plane motion of the pelvis during gait. Femoral offset subgroups demonstrated no significant differences for patient-reported function scores and outcomes of the Trendelenburg Test and gait analysis. INTERPRETATION: Reduced hip offset and leg length discrepancy following hip arthroplasty seem to be marginally associated with worse clinical outcomes.

Who owns responsibility? An administrator's take on implementing time-variable medical training in teaching hospitals.

Introduction: Developments in outcome-based medical education led to the introduction of time-variable medical training (TVMT). Although this idea of training may be a consequence of competency-based training that calls for individualized learning, its implementation has posed significant challenges. As a new paradigm it is likely to have repercussions on the organization of teaching hospitals. The purpose of this study is therefore to explore how hospital administrators cope with this implementation process. Methods: We conducted an exploratory qualitative study for which we interviewed administrators of hospitals who were actively implementing TVMT in their postgraduate programs. Results: Several problems of implementation were identified: existing governance structures proved unfit to cope with the financial and organizational implications of TVMT. Administrators responded to these problems by delegating responsibilities to departments, reallocating tasks, learning from other hospitals and scaling up their teaching facilities. Conclusions: Hospital administrators perceived the implementation of TVMT as challenging. TVMT affects the existing equilibrium between education and clinical service. Administrators' initial attempts to regain control, using steering strategies that were based on known concepts and general outcomes, including cutting departmental budgets did not work, nor did their subsequent wait-and-see approach of leaving the implementation to the individual departments.

Experienced barriers in shared decision-making behaviour of orthopaedic surgery residents compared with orthopaedic surgeons.

INTRODUCTION: In shared decision-making (SDM), physicians encourage the patient to participate in the care process. The theory of planned behaviour describes that behaviour is dependent on intention. In its turn, intention is explained by attitude, subjective norm and perceived behavioural control. In orthopaedics, little is known about current SDM behaviour and how to promote it.The aim of the present study was to gain insight into the SDM behaviour of orthopaedic residents and supervisors by measuring levels of intention, attitudes, subjective norms and perceived behavioural control. Furthermore, we aimed to determine the predictors of intention for SDM. METHODS: A questionnaire survey study was conducted among orthopaedic surgeons and residents working in the care of hip and knee osteoarthritis, to determine their intentions, attitudes, subjective norms and perceived behavioural control regarding SDM. RESULTS: Of the 385 physicians approached, 71 residents and 64 orthopaedic surgeons participated. Residents and the supervisors alike had positive intentions regarding SDM. Intention for SDM behaviour was explained by attitude, subjective norm and perceived behavioural control, with perceived behavioural control having the strongest association. In residents, the intention to engage in SDM was more hampered by a lower level of perceived behavioural control than in surgeons. CONCLUSIONS: Physicians are willing to perform SDM and consider SDM as favourable in the orthopaedic clinic. The implementation of SDM is mainly hampered by experienced barriers that they cannot control. These findings underline the importance of incorporating SDM in the curriculum of postgraduates. Possibilities for efficient SDM implementation should be explored, to overcome perceived barriers.

Metal ion concentrations after metal-on-metal hip arthroplasty are not correlated with habitual physical activity levels.

INTRODUCTION: Metal-on-metal (MoM) hip arthroplasties have shown high clinical failure rates with many patients at risk for a revision and under surveillance for high metal ion concentrations. Implant wear releasing such ions is assumed to be a function of use, i.e. the patient's physical activity. This study aimed to assess whether habitual physical activity levels of MoM patients are correlated with metal ion concentrations and are higher in patients with high (at risk) than in patients with low (safe) metal ion concentrations. METHODS: A cohort study was conducted of patients with any type of MoM hip prosthesis. Metal ion concentrations were determined using ICP-MS. Habitual physical activity of subjects was measured in daily living using an acceleration-based activity monitor. Outcome consisted of quantitative and qualitative activity parameters. RESULTS: In total, 62 patients were included. Mean age at surgery was 60.8 ± 9.3 years and follow-up was 6.3 ± 1.4 years. Cobalt concentrations were highly elevated overall (112.4 ± 137.9 nmol/L) and significantly more in bilateral (184.8 ± 106.5 nmol/L) than in unilateral cases (87.8 ± 139.4 nmol/L). No correlations were found between physical activity parameters and metal ion concentrations. Subgroup analysis of patients with low versus high cobalt concentration showed no significant differences in habitual physical activity. DISCUSSION: No correlation was found between physical activity levels and metal ion concentrations. Implant use by normal habitual activities of daily living seems not to influence metal ion concentrations.

Performance on a Single-Legged Drop-Jump Landing Test Is Related to Increased Risk of Lateral Ankle Sprains Among Male Elite Soccer Players: A 3-Year Prospective Cohort Study.

BACKGROUND: Soccer has a high injury rate, with lateral ankle sprains being a common injury. Therefore, an approach to prevent or at least reduce the occurrence is warranted. Injury prevention can be improved by identifying specific risk factors and individuals at risk. PURPOSE: To assess drop-jump landing performance as a potential predictor of lateral ankle sprain within 3-year follow-up. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Single-legged drop-jump landing tests were performed by 190 elite soccer players. Based on ground-reaction forces, 6 outcome measures were calculated that aim to reflect the impact and stabilization phase. Lateral ankle sprains were registered during up to 3 years of follow-up. Following a z score correction for age, a multivariate regression analysis was performed. RESULTS: During follow-up, 45 players (23.7%) suffered a primary lateral ankle sprain. Of those, 34 were regarded as severe (absence >7 days). Performance was related to increased risk of ankle sprain ( P = .005 for all sprains and P = .001 for severe sprains). Low mediolateral stability for the first 0.4 seconds after landing (a larger value indicates more force exerted in the mediolateral direction, resulting in rapid lateral stabilization) and high horizontal ground-reaction force between 3.0 and 5.0 seconds (a smaller value indicates less sway in the stabilization phase) were identified as risk factors. A player that scored 2 SD below average for both risk factors had a 4.4-times-higher chance of sustaining an ankle sprain than a player who scored average. CONCLUSION: The current study showed that following a single-legged drop-jump landing, mediolateral force over 0 to 0.4 seconds and/or mean resultant horizontal ground-reaction force over 3 to 5 seconds has predictive value with regard to the occurrence of an ankle sprain among male elite soccer players within 3 years.

Efficacy of Nutritional Intervention in Elderly After Hip Fracture: A Multicenter Randomized Controlled Trial.

Background: Malnutrition after hip fracture is associated with increased rehabilitation time, complications, and mortality. We assessed the effect of intensive 3 month nutritional intervention in elderly after hip fracture on length of stay (LOS). Methods: Open-label, randomized controlled trial. Exclusion criteria: age < 55 years, bone disease, life expectancy < 1 year, bedridden, using oral nutritional supplements (ONS) before hospitalization, and cognitive impairment. Intervention: weekly dietetic consultation, energy-protein-enriched diet, and ONS (400 mL per day) for 3 months. Control: usual nutritional care. Primary outcome: total LOS in hospital and rehabilitation clinic, including readmissions over 6 months (Cox regression adjusted for confounders); hazard ratio (HR) < 1.0 reflects longer LOS in the intervention group. Secondary outcomes: nutritional and functional status, cognition, quality of life, postoperative complications (6 months); subsequent fractures and all-cause mortality (1 and 5 years). Effect modification by baseline nutritional status was also tested. Results: One hundred fifty-two patients were randomized (73 intervention, 79 control). Median total LOS was 34.0 days (range 4-185 days) in the intervention group versus control 35.5 days (3-183 days; plogrank = .80; adjusted hazard ratio (adjHR): 0.98; 95% CI: 0.68-1.41). Hospital LOS: 12.0 days (4-56 days) versus 11.0 days (3-115 days; p = .19; adjHR: 0.75; 95% CI: 0.53-1.06) and LOS in rehabilitation clinics: 19.5 days (0-174 days) versus 18.5 days (0-168 days; p = .82; adjHR: 1.04; 95% CI: 0.73-1.48). The intervention improved nutritional intake/status at 3, but not at 6 months, and did not affect any other outcome. No difference in intervention effect between malnourished and well-nourished patients was found. Conclusions: Intensive nutritional intervention after hip fracture improved nutritional intake and status, but not LOS or clinical outcomes. Paradigms underlying nutritional intervention in elderly after hip fracture may have to be reconsidered.

Discrepancy and contradiction regarding fixation of hip stems with or without cement: survey among 765 hip arthroplasty specialists.

INTRODUCTION: The growing use of cementless stems is associated with an increase in implant-related complications. This global survey study investigates which parameters orthopaedic surgeons currently consider for either cemented or cementless stem fixation in primary total hip arthroplasty (THA). METHODS: A survey regarding current practice patterns was distributed among hip arthroplasty specialists. Key questions concerned: (i) frequency of using cemented/cementless stems; (ii) frequency of using parameters which influence a choice between both; (iii) usage of specific cut-off values for parameters. RESULTS: 507 (out of 765) respondents, having at least 5 years' experience and performing at least 50 cases a year, were selected for analysis. Respondents using both fixation techniques ( n = 413; 81%) use a cementless stem in 69% and a cemented stem in 31%. The choice is most frequently based on: (i) patient age; (ii) cortical thickness; (iii) femoral canal shape; (iv) bone mineral density; and (v) stem fit on preoperative templating. 57% using both fixation techniques do not use a specific cut-off value for age. 92% of the respondents that do use a cut-off value for age use exclusively cemented stems in patients being ⩾72.7 years (median 75; range 50-90 years). Considerable discrepancy and even contradictory responses were present regarding the other parameters and the use of specific cut-off values. CONCLUSIONS: Current practice patterns regarding stem fixation in primary THA vary substantially among orthopaedic surgeons. Evidence-based guidelines are needed to define which parameters and threshold values support the best individual choice for hip stem fixation.

Current practice of orthopaedic surgical skills training raises performance of supervised residents in total knee arthroplasty to levels equal to those of orthopaedic surgeons.

AIM: To investigate whether the current, generally accepted practice of orthopaedic surgical skills training can raise the performance of supervised residents to levels equal to those of experienced orthopaedic surgeons when it comes to clinical outcomes or implant position after total knee arthroplasty. METHODS: In a retrospective analysis of primary total knee arthroplasty outcomes (minimum follow-up of 12 months) procedures were split into two groups: supervised orthopaedic residents as first surgeon (group R), and experienced senior orthopaedic surgeons as first surgeon (group S). Outcome data that were compared 1 year postoperatively were operation times, complications, revisions, Knee Society Scores (KSS) and radiological implant positions. RESULTS: Of 642 included procedures, 220 were assigned to group R and 422 to group S. No statistically significant differences between the two groups were found in patient demographics. Operation time differed significantly (group R: 81.3 min vs. group S: 71.3 min (p = 0.000)). No statistically significant differences were found for complications (p = 0.659), revision rate (p = 0.722), femoral angle (p = 0.871), tibial angle (p = 0.804), femoral slope (p = 0.779), tibial slope (p = 0.765) and KSS (p = 0.148). DISCUSSION AND CONCLUSION: Supervised residents needed 10 minutes extra operation time, but they provided the same quality of care in primary total knee arthroplasty as experienced orthopaedic surgeons concerning complication rates, revisions, implant position on radiographs and KSS. The currently used training procedure in which the supervising surgeon and the resident decide if the resident is ready to be first surgeon is safe for patients.

Effects of implementing time-variable postgraduate training programmes on the organization of teaching hospital departments.

INTRODUCTION: As competency-based education has gained currency in postgraduate medical education, it is acknowledged that trainees, having individual learning curves, acquire the desired competencies at different paces. To accommodate their different learning needs, time-variable curricula have been introduced making training no longer time-bound. This paradigm has many consequences and will, predictably, impact the organization of teaching hospitals. The purpose of this study was to determine the effects of time-variable postgraduate education on the organization of teaching hospital departments. METHODS: We undertook exploratory case studies into the effects of time-variable training on teaching departments' organization. We held semi-structured interviews with clinical teachers and managers from various hospital departments. RESULTS: The analysis yielded six effects: (1) time-variable training requires flexible and individual planning, (2) learners must be active and engaged, (3) accelerated learning sometimes comes at the expense of clinical expertise, (4) fast-track training for gifted learners jeopardizes the continuity of care, (5) time-variable training demands more of supervisors, and hence, they need protected time for supervision, and (6) hospital boards should support time-variable training. CONCLUSIONS: Implementing time-variable education affects various levels within healthcare organizations, including stakeholders not directly involved in medical education. These effects must be considered when implementing time-variable curricula.