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Association of surgical experience with risk of complication in total hip arthroplasty among patients with severe obesity

Charalambous A, Pincus D, High S, Leung F, Aktar S, Paterson JM, Redelmeier DA, Ravi B. JAMA Netw Open. 2021; 4(9):e2123478. Epub 2021 Sep 1. DOI:

Importance — Severe obesity is a risk factor for major early complications after total hip arthroplasty (THA).

Objective — To determine the association between surgeon experience with THA in patients with severe obesity and risk of complications.

Design, Setting, and Participants — This retrospective population-based cohort study was performed in Ontario, Canada, from April 1, 2007, to March 31, 2017, with data analysis performed from March 2020 to January 2021. A cohort of patients who received a primary THA for osteoarthritis and who also had severe obesity (body mass index [calculated as weight in kilograms divided by height in meters squared] ≥40) at the time of surgery was defined. These patients were identified using the Canadian Institute for Health Information Discharge Abstract Database and physician claims from the Ontario Health Insurance Plan. Generalized estimating equations were used to determine the association between overall THA and severe obesity-specific THA surgeon volume and the occurrence of complications after controlling for potential confounders. The study hypothesized that surgeon experience specific to patients with severe obesity could further reduce the risk of complications.

Exposures — Primary THA.

Main Outcomes and Measures — Complications were considered as a composite outcome (revision, infection requiring surgery, or dislocation requiring reduction), within 1 year of surgery. This was defined before the study, as was the study hypothesis.

Results — A total of 4781 eligible patients was identified. The median age was 63 (interquartile range [IQR], 56-69) years, and 3050 patients (63.8%) were women. Overall, 186 patients (3.9%) experienced a surgical complication within 1 year of surgery. The median overall THA surgeon volume was 70 (IQR, 46-106) cases/y, whereas the median obesity-specific surgeon volume was 5 (IQR, 2-9) cases/y. After controlling for patient and hospital factors, greater obesity-specific THA surgeon volume (adjusted odds ratio per additional 10 cases, 0.65 [95% CI, 0.47-0.89]; P = .007), but not greater overall THA surgeon volume (adjusted odds ratio per 10 additional cases, 0.97 [95% CI, 0.93-1.02]; P = .24), was associated with a reduced risk of complication.

Conclusions and Relevance — Increased surgeon experience performing THA in patients with severe obesity was associated with fewer major surgical complications. These findings suggest that surgeon experience is required to mitigate the unique anatomical challenges posed by surgery in patients with severe obesity. Referral pathways for patients with severe obesity to surgeons with high obesity-specific THA volume should be considered.

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