Think back to the first time you performed a complex task. It probably didn’t go as well as the 50th or 100th time you did it, right? The same dynamic holds with surgeons doing repairs of the knee’s anterior cruciate ligament, or ACL, according to a study presented earlier this week at a meeting of the American Academy of Orthopedic Surgeons. While it’s not surprising that there’s a learning curve with surgery, it was still striking to see the actual figures “shown in a fairly dramatic way,” says Robert Marx , an author of the study and an orthopedic surgeon at the Hospital for Special Surgery and professor of orthopedic surgery at the Weill Cornell Medical College. The study, which drew from a New York State Department of Health database, found that if a patient’s ACL repair surgery was among the first ten such cases of a surgeon’s career, the patient had about five times the risk of having another ACL repair within a year as a patient whose surgeon had already performed more than 150 of the operations. (To be sure, even among less experienced physicians, the risk of another reconstruction within a year was pretty low — about 1.7%.) As surgeons perform more of a certain procedure, they get better and better at avoiding pitfalls that can take up extra time and in some cases cause major problems and

affect outcomes, says Marx. ACL surgery, while routine, is “fairly complex,” he says; the potential pitfalls include incorrectly placing the graft, not fixing it solidly and not recognizing other ligaments in the area that could also be injured. One limitation of the study is that it only tracked further reconstructive surgeries done within a year of the original operation, when a surgeon’s skill could affect the rate of further surgeries years in the future, says Marx. And the data can’t indicate whether the subsequent surgery was done on the same knee as the original operation — though re-operations are usually in the same leg, he says. Given that a learning curve is to some degree inevitable, what can be done? Marx says it might be possible to supervise surgeries earlier in a physician’s career, or to use medical simulators in training. The study showed a subspecialty fellowship didn’t significantly improve the learning curve, which Marx says may be due to the variability of training programs. “The bottom line is you can do residency, you can do a fellowship, but at the end of the day you have to go do this on your own,” he says. “There’s no substitute for doing independent surgery.” Bonus: NEJM Study: Some ACL Tears May Not Need Quick Surgery Photo: iStockphoto

Here is the original post: 
A Learning Curve For Surgeons Doing ACL Repairs