Open Access Research article

The role of surgeon volume on patient outcome in total knee arthroplasty: a systematic review of the literature

Rick L Lau1*, Anthony V Perruccio2, Rajiv Gandhi3 and Nizar N Mahomed3

Author Affiliations

1 Division of Orthopaedics, Department of Surgery Kingston General Hospital, Queen’s University, 76 Stuart St., Nickle 3, Rm 9-309, Kingston, ON, K7L 2V7, Canada

2 Division of Orthopaedic Surgery and The Arthritis Program Toronto Western Hospital, University Health Network Institute of Health Policy, Management and Evaluation, University of Toronto, 399 Bathurst St., EW 1-427, Toronto, ON, M5T 2S8, Canada

3 Division of Orthopaedics, Department of Surgery Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst St., EW 1-439, Toronto, ON, M5T 2S8, Canada

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BMC Musculoskeletal Disorders 2012, 13:250  doi:10.1186/1471-2474-13-250

Published: 14 December 2012

Abstract

Background

A number of factors have been identified as influencing total knee arthroplasty outcomes, including patient factors such as gender and medical comorbidity, technical factors such as alignment of the prosthesis, and provider factors such as hospital and surgeon procedure volumes. Recently, strategies aimed at optimizing provider factors have been proposed, including regionalization of total joint arthroplasty to higher volume centers, and adoption of volume standards. To contribute to the discussions concerning the optimization of provider factors and proposals to regionalize total knee arthroplasty practices, we undertook a systematic review to investigate the association between surgeon volume and primary total knee arthroplasty outcomes.

Methods

We performed a systematic review examining the association between surgeon volume and primary knee arthroplasty outcomes. To be included in the review, the study population had to include patients undergoing primary total knee arthroplasty. Studies had to report on the association between surgeon volume and primary total knee arthroplasty outcomes, including perioperative mortality and morbidity, patient-reported outcomes, or total knee arthroplasty implant survivorship. There were no restrictions placed on study design or language.

Results

Studies were variable in defining surgeon volume (‘low’: <3 to <52 total knee arthroplasty per year; ‘high’: >5 to >70 total knee arthroplasty per year). Mortality rate, survivorship and thromboembolic events were not found to be associated with surgeon volume. We found a significant association between low surgeon volume and higher rate of infection (0.26% - 2.8% higher), procedure time (165 min versus 135 min), longer length of stay (0.4 - 2.13 days longer), transfusion rate (13% versus 4%), and worse patient reported outcomes.

Conclusions

Findings suggest a trend towards better outcomes for higher volume surgeons, but results must be interpreted with caution.

Keywords:
Surgeon volume; Knee arthroplasty