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Analysis of the relationship between surgeon procedure volume and complications after total knee arthroplasty using a propensity-matched cohort study

Okoro T, Tomescu S, Paterson JM, Ravi B. BMJ Surg Interv Health Technologies. 2021; 3:e000072. Epub 2021 Apr 2. DOI:

Objectives — This study aimed to identify a threshold in annual surgeon volume associated with increased risk of revision (for any cause) and deep infection requiring surgery following primary elective total knee arthroplasty (TKA).

Design — A propensity score matched cohort study.

Setting — Ontario, Canada.

Participants — 169 713 persons who received a primary TKA between 2002 and 2016, with 3-year postoperative follow-up.

Main Outcome Measures — Revision arthroplasty (for any cause), and the occurrence of deep surgical infection requiring surgery.

Results — Based on restricted cubic spline analysis, the threshold for increased probability of revision and deep infection requiring surgery was <70 cases/year. After matching of 51 658 TKA recipients from surgeons performing <70 cases/year to TKA recipients from surgeons with greater than 70 cases/year, patients in the former group had a higher rate of revision (for any cause, 2.23% (95% Confidence Interval (CI) 1.39 to 3.07) vs 1.70% (95% CI 0.85 to 2.55); Hazard Ratio (HR) 1.33, 95% CI 1.21 to 1.47, p<0.0001) and deep infection requiring surgery (1.29% (95% CI 0.44 to 2.14) vs 1.09% (95% CI 0.24 to 1.94); HR 1.33, 95% CI 1.17 to 1.51, p<0.0001).

Conclusions — For primary TKA recipients, cases performed by surgeons who had performed fewer than 70 TKAs in the year prior to the index TKA were at 31% increased relative risk of revision (for any cause), and 18% increased relative risk for deep surgical infection requiring surgery, at 3-year follow-up.

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