How Much, Really, Does Surgeon Skill Drive TKA Outcomes?

Why has the 20-30% total knee arthroplasty (TKA) dissatisfaction rate been so durable a problem?

A new study from Cleveland Clinic investigated one possible factor—surgeon-level variability—and the results of their work, “The Impact of Surgeon Variability on Patient-Reported Outcome Measures, Length of Stay, Discharge Disposition, and 90-Day Readmission in TKA,” appears in the November 16, 2022, edition of The Journal of Bone and Joint Surgery.

Co-author Nicolas S. Piuzzi, M.D., director of the Cleveland Clinic Adult Joint Reconstruction Research, and co-author explained the genesis of the study to OTW, “The vision that our Cleveland Clinic Adult Joint Reconstruction & Research Program has is to advance hip and knee arthroplasty personalized patient care through evidence-based orthopaedic practice. This study was the result of one of our strategic areas: Total joint outcomes (patient-reported outcome measures, satisfaction, complications).”

“As the number of patients being treated with TKA continues to rise worldwide year after year, we need to better understand personalized methods to attenuate the risk of adverse outcomes and improve patient satisfaction following surgery.”

“Previous literature has examined the efficacy of various orthopaedic technologies and practices, including robot-assisted procedures, implant designs, surgical techniques, and care pathways.”

“Still, knowledge with regard to inter-surgeon variability is limited, and previous studies have not always considered the influence of this variability within statistical analyses.”

One Institution, Multiple Surgeons, Multiple Outcomes

The team prospectively collected data on 5,429 patients who had TKA with 1 of 36 surgeons at Cleveland Clinic between 2016 and 2018. When the team analyzed their data, they found evidence of which tied patient outcomes to surgeon variability.

“Our study suggests the presence of variability between surgical practices in the setting of primary TKA at a single healthcare system,” said Dr. Piuzzi to OTW. “There was a significant association between surgeon and the Knee Injury and Osteoarthritis Outcome Score-Pain, Physical Function, Joint Replacement, length of stay, discharge disposition, and 90-day readmission.”

“Variability in outcomes between surgical practices, although measurable, could not be attributed to surgical volume. When assessed as a variable, the individual surgeon was a greater driver of 1-year patient-reported outcome measures, length of hospitalization, discharge location, and 90-day readmission than many patient-level characteristics, including sex, comorbidity, and baseline function.”

“This study highlights the need to continue to further explore the ‘surgeon variable’ as this comprises multiple aspects of the surgical team (e.g., assistants, nurses, therapists). This variable is not only composed of surgical technique but also comprises elements of patient selection for TKA as well as postoperative care and elements of rehabilitation protocol. Although each surgeon’s team followed the same clinical pathway, there was no measurement of compliance in the current study and thus, individual differences may have occurred.”

“Additional investigation aimed at elucidating the specific aspects of the ‘surgeon variable’ that give rise to the observed variability should also be conducted to further augment orthopaedic care in the setting of TKA. Finally, given these results, consideration of inter-surgeon variability when model-fitting would serve to mitigate confounding in future arthroplasty research.”