I Completed 80 Arthroplasty Operations! My Experience of the Learning Curve

Learning how to perform an arthroplasty (a joint replacement) is a mandated part of the Trauma & Orthopaedic (T&O) Surgery national curriculum. As it stands, the T&O Specialty Advisory Committee (SAC) have advised that 80 operations as the first surgeon constitute the indicative number of arthroplasties that must be completed during Registrar training. This number has been met with murmurs of discontent over the years but has nevertheless remained steadfast due to a consensus that 80 operations provide an appropriate learning curve for Registrar orthopaedic surgeons training to be Consultant orthopaedic surgeons.

Now, 80 operations are not easy to achieve, particularly when so many colleagues across the country often find themselves short even in the most senior of years of the training programme. The reason is that these are protected procedures due to the devastating nature of complications and so it’s imperative they are performed to a very high standard by the operating surgeon. Additionally, the advent of national registries and initiatives such as Get it Right First Time (GIRFT) have further increased the level of scrutiny on arthroplasty standards. Furthermore, thousands of NHS cases have been transferred to the independent sector to help reduce the waiting list. Whilst the rationale to ensure arthroplasty operations are performed to a high standard is appreciable, the protective measures have rendered arthroplasty less available for Registrar surgeons and reduced the opportunities for us to hone our skills to meet the expected level of competency.

As I approach the end of my first 6 months of ST5, I’ve been fortunate enough to surpass the SAC requirement of 80 arthroplasty operations through 3 back-to-back hip and knee surgery rotations, breathing a sigh of relief at having achieved the milestone. However, this also provided the perfect juncture to reflect on the learning curve and my developmental trajectory over the last 18 months.

Let’s wind back to the start. My first lower limb arthroplasty rotation took place in a high volume district general hospital, where I had two clinical supervisors, both of whom were lower limb arthroplasty consultants performing primary joint replacements on a full day operating list every single week. Four joint replacements were performed on an average list, and if not, it would be 1 or 2 soft tissue knee procedures followed by 2 joint replacements. My learning curve was steep and fast as I got to grips with the operating techniques. It honestly felt like chaos as my mind was thrown into mayhem given the weird orientation of anatomy during a hip replacement and the 3-D approach to knee replacements – can you relate? In accordance with normal practice, the level of supervision was extremely high during the earlier stages and so I learned the techniques of arthroplasty with my hands held tightly. Credit where credit is due, my clinical supervisors at the time both had the patience of a saint and a steely resolve given my level of juniority and sluggish understanding of the principles of hip and knee replacement surgery. In spite of this, we would still achieve four joint replacements per list, which is a testament to the training I received and the efficiency of the theatre staff. I exited that rotation with 35 arthroplasty numbers as a new ST4.

Having had a chance to reflect and employ the power of hindsight, I can offer up the following main priorities which I feel would be critical to pin down when starting your first arthroplasty rotation:

1. Read the hip and knee book from start to finish. This is a free orthopaedic holy text that a true saint called Dr Bert Parcells published for all of us to read and learn from. Main points to nail are native knee alignment and corresponding surgical alignment philosophies (don’t over-complicate it at an early stage – just learn what mechanical and kinematic alignment are, that’s all), and hip anatomy/biomechanics (offset and version etc.) and radiographic lines.
2. Read some biomechanics. I know this is boring for many, but it’s so critical to understanding the “why” of arthroplasty and demystifies so much current practice and surgical dogma. Break it down into bite-sized, manageable chunks: i) force, stress, and strain; ii) stress-strain curve; iii) material properties of common implants e.g. De Puy Synthes Corail Pinnacle, Stryker Exeter, De Puy Synthes Attune, Smith and Nephew Genesis II, Zimmer-Biomet Nex-Gen or Persona, etc.; iv) lubrication (part of tribology); v) and finally, wear (modes and types).
3. Read the operative technique booklet from the implant(s) that your clinical supervisor uses. This will give you an idea of the steps involved in the operation. The clinical reading above that you’ll do alongside this will help you understand why each step is performed.
4. Learn to assist for hip and knee arthroplasty. This is the first critical step of technical skill acquisition. You can’t run before you’ve learned to walk and I learned that the hard way. This is because correct assistance plays a huge role in the success of the case. For example, if the tibia is not held vertically during instrumentation of the femur prior to implantation during a total hip replacement, the entire version can be miscalculated and the implant will end up in the wrong position, thereby destabilising the new hip. Similarly, if the collateral ligaments are not properly protected with retractors during a total knee replacement, the risk of damage to these structures is high and can result in unwanted instability of the new knee. The list goes on, but the key point is that you need to understand the how and why behind the methods of assistance during arthroplasty, so you know how to perform each step correctly when you’re on the other side of the operating table. Trust me, the learning curve will be much better.

My second 6-month rotation was with an excellent clinical supervisor who was an expert in both soft tissue knee surgery, and hip and knee arthroplasty. This was useful in the sense that it provided me with a better understanding of the non-bony aspect of the knee joint, along with an opportunity to approach arthroplasty with fresh eyes and a bit of experience under my belt. Operative numbers-wise, I achieved about 12 joint replacements across the 6 months, but I gained more knowledge and hands on experience of soft tissue knee procedures such as anterior cruciate ligament (ACL) reconstruction and complex lower limb trauma. My clinical supervisor was meticulous, pushing me out of my comfort zone to develop my skills, and a fierce advocate of reading and learning to do things the correct way, reflecting his accolade as one of the “scarier” FRCS (Fellowship of the Royal College of Surgeons – the final exam we sit before being eligible to apply for Consultant jobs) examiners.

The final and most recent 6-month rotation has been, in my opinion, the most formative for me. This was the home straight and involved biweekly operating lists with my clinical supervisors, both of whom performed primary hip and knee replacements, as well as some complex work. Both are fantastic trainers and pushed me during every operating list, instilling the principles of prior planning and accurately executing the plan to minimise the risk of unwanted and unplanned complications. The development of techniques, knowledge, and decision making was in full flow, powering through the second, dedicated stage of the arthroplasty learning curve. At last I felt like things were starting to click into place. I was understanding the hip and knee as multidimensional joints that involved numerous planes of motion. I found attending a knee arthroplasty course and an update in arthroplasty conference boosted my knowledge and confidence ten-fold.

Now that I’m on the other side of the Training Programme learning curve, so to speak, I have a selection of reflections and tips that I acquired along the way which I thought I’d share just in case they’re of any use to others or perhaps relatable:

1. The beginning is tough. Nothing makes sense, you feel exhausted at the end of the operation, and it feels as though there’s way too much to think about. There were many times where I was tempted to take the easy route out and let the boss do the cases. But there’s a breakthrough at around 10 knees and 10 hips. It’s important to persist and learn the basic principles of arthroplasty – this will help a lot. Just be aware of the first Dunning-Kruger peak (unconscious incompetence) and remember your limitations…
2. The second wind starts after your first 40 or so joints. This is where you’re perhaps approaching the “Valley of Despair” or consciously incompetent part of the Dunning-Kruger curve. It’s where you move from incorrectly believing arthroplasty isn’t so bad in the beginning, to somewhat fearing it. Suddenly you’ve gone back to nothing making sense and it’s challenging to continue without feeling like you’ve gone back to square one.
3. As you reach 60 joints, things start to make more sense again. The operative technique is now a bit more routine to replicate for low complexity cases and you’ve started to learn nuances that you can utilise to adapt to a variety of situations. I did a course during this time, but I’d strongly encourage to do it earlier. Having said that, doing the course at a later stage meant that I already knew the basic principles and could therefore refine and ameliorate my knowledge.
4. The milestone of 80 is a really interesting moment. Whilst it means very little in the grand scheme of things, especially if you want to pursue arthroplasty as a career choice, it does come with a strange sense of being ready to move onto the next steps of the learning curve. Whether it’s robot-assisted surgery, or more complicated cases, the readiness to progress organically arises.

So, that’s a whistle-stop tour of my arthroplasty experience, as told from this milestone moment. I think the fundamental take home message would be that the journey is a lengthy and complicated one, full of peaks and troughs, but with an abundance of small, transferrable skills that can be learned along the way. At the risk of sounding condescending, the learning curve is worth it and patience will be your best virtue. Keep going as it’s a cool feeling at the end.

Good luck, and peace out for now ✌🏽.