Optimising surgical training in primary total hip replacement
Keywords: surgical training
orthopaedic surgery
simulation
hip replacement

Primary total hip replacement (THR) is one of the most performed and successful operations of the 21st Century. However, despite its prevalence and importance, no agreed teaching methods exist for THR overall, or for any of its key steps. Furthermore, little research has been conducted investigating the learning curve of trainees in THR or attempts made to optimise training in this operation using an evidence-based approach. This thesis aims to develop and evaluate novel simulation training methods to improve surgeon performance and patient outcomes in elective primary THR.
A retrospective case series of 348 primary THR demonstrated that operative times and postoperative radiographs cannot be solely used in defining the learning curve and technical skills progression of specialty registrars (StRs) across a 6-month placement. Analysis of National Joint Registry data identified a recent trend for increased early and potentially avoidable revision operations following elective primary THR performed by unsupervised surgical trainees. This highlights the importance of appropriate supervision during trainee performed THR, and the need for continued improvements in training. Expert consensus methodology was used to deconstruct, define, and rank the key steps of a primary THR, and the results used to develop an evidence-based training module for surgical trainees. The impact of this module was then assessed in both simulated laboratory and clinical environments in a group of 34 orthopaedic trainees. A trend for improved knowledge acquisition and templating in THR was observed following simulation training, but no significant differences were observed in simulated skin incision marking, or component orientation tasks. Novel motion analysis techniques have been developed and validated for assessing the intra-operative technical skills performance of surgeons during primary THR. Trainees were significantly slower and performed more movements than consultants in most steps of this operation. However, no significant differences were observed in blood loss, transfusion requirements, patient-reported outcome measures, or post-operative radiographic parameters in relation to surgeon experience. These results support the safety and efficacy of supervised training in THR in relation to patient outcomes. No meaningful clinically important differences were observed in surgeon performance or patient outcome metrics following simulation training in trainee performed THR. However, the small number of trainee (n=7) and patient (n=52) participants in this study were notable limitations.
This research fills an important gap in knowledge regarding how to best train surgeons in primary THR and has identified areas for targeted future improvement in training, which may ultimately benefit patients, trainers, and trainees. Organisations and individuals responsible for delivering surgical training should use the findings of this research to maximise the operative experience of trainees during clinical placements, ensure adequate intra-operative supervision, and consider the use and integration of both simulation training and objective metrics for training and assessing performance, competence, and progression through a training program.