Research from England and Wales shows no difference in long-term outcomes for knee surgery performed by trainee surgeons and experienced consultants.
The new study significantly boosts surgical training programmes by revealing that partial knee replacements (unicompartmental knee replacements, or UKRs) performed by trainee surgeons last as long as those conducted by fully trained consultants.
The research, which analysed over 100,000 procedures carried out between 2003 and 2019, suggests no significant difference in the rates of subsequent revision surgeries – indicating that the UK’s current training methods produce highly skilled surgeons capable of delivering successful patient outcomes.
The study, conducted using data from the National Joint Registry (NJR) for England and Wales, involved 106,206 UKR procedures performed on 91,626 patients with osteoarthritis.
The findings challenge the long-held concern that trainee-performed procedures, particularly those done with minimal supervision, might lead to inferior results compared to operations performed by senior consultants.
UKRs are a standard treatment option for patients with isolated osteoarthritis in one part of the knee, often viewed as a less invasive alternative to total knee replacement (TKR).
The National Institute for Health and Care Excellence (NICE) recommends patients with isolated medial compartment osteoarthritis be offered the option of UKR, citing advantages such as faster recovery, better functional outcomes, and fewer post-surgery complications compared to TKR.
However, one downside of UKR is its higher revision rate compared to total knee replacement, raising concerns about the durability of the implants, primarily when less experienced surgeons perform surgeries.
This study sought to determine whether knee replacement procedures carried out by trainee surgeons at various training stages are as durable as those performed by fully qualified consultants.
The researchers analysed prospectively collected data from the NJR, the largest joint replacement registry in the world. They examined the primary outcome of ‘all-cause revision surgery’ – a procedure where the original implant needs to be replaced for various reasons, including implant failure, infection, or the progression of osteoarthritis.
Of the 106,206 procedures analysed, 4,382 (4.1%) were performed by trainee surgeons. The study also distinguished between surgeries where trainees were supervised directly by a scrubbed consultant and those without such supervision.
Whether or not a trainee was supervised during surgery, the long-term outcomes remained comparable to those performed by consultants.
At the 15-year follow-up mark, the cumulative probability of failure was nearly identical for both groups: 16.42% for trainee-performed surgeries and 17.13% for consultants.
Even when comparing supervised and unsupervised trainees, the revision rates remained similar, with no statistically significant difference in the risk of revision surgery.
The revision rate for procedures performed by trainees not supervised by a scrubbed consultant was 17.32%, nearly the same as the 17.13% rate for consultants. This suggests that even unsupervised trainees achieve long-term outcomes similar to those of their senior counterparts.
These results significantly endorse the current methods by which surgeons are trained in the UK. The study’s lead researchers emphasised that the findings should reassure the surgical community and patients that the standard of care provided by trainees is not compromised, even as they gain hands-on experience in performing complex operations like UKR.
The British Association for Surgery of the Knee (BASK) and the European Knee Society (EKS) have long advocated for UKRs to be a part of knee surgeons’ training, given the benefits of this procedure for select patients with localised osteoarthritis. This study reinforces those recommendations and proves that training surgeons to perform UKRs is safe and effective.
While the study’s findings are overwhelmingly positive, the authors acknowledge limitations inherent to its observational design.
