Accuracy of acetabular cup placement positively correlates with level of training

Accurate acetabular component placement may reduce the risk of complication after total hip arthroplasty (THA). While surgeon experience and volume may reduce outliers, little is known how cup positioning accuracy and consistency relates to level of training (resident, fellow, attending) and whether trainee level impacts the magnitude and direction of cup placement errors.

Ninety patients undergoing posterolateral computer-assisted navigation THA were included for analysis. All surgery was performed by two fellowship-trained orthopaedic surgeons and assisted by a trainee (orthopedic resident (PGY 1-5) or fellow in adult reconstruction). In order to determine accuracy of cup placement in trainees and attendings, we used computer navigation to determine freehand cup placement by the trainee, then by the attending surgeon. Final cup inclination and version were determined and recorded by computer-assisted surgical navigation. Comparison of consistency in cup inclination and anteversion was made on values obtained by residents, fellows, and attendings and final values provided by the navigation system. In addition, to assess the role of training and repetition, acetabular cup inclination and version were compared between fellows during the first half and the second half of their training year. All comparisons were performed with the Student t-test except for comparison of rate of deviation from the safe zone, which were performed with the chi-square test. The level of significance was defined as p values ≤ 0.05 with 95% confidence interval, and trend toward significance was defined as p values ≤ 0.1.

Inclination deviation from the final position and cup version deviation from the final position were statistically significant between resident vs attendings (p < 0.001 (inclination), p < 0.001 (version)), fellow vs attendings (p < 0.001 (inclination), p < 0.001 (version)), and all trainee vs attendings (p < 0.001 (inclination), p < 0.001 (version)). In all comparisons, the attending surgeons placed the cup closer to the final cup position than both resident and fellows. Proportion of inclination deviation from the safe zone of residents was significantly higher than of attendings (p < 0.001) but no significant difference was observed between fellows and attending (p = 1.00). Compared to residents, fellows demonstrated lower proportion of inclination deviation from the safe zone of 3.3% vs 23.3% for fellows vs residents (p = 0.002) and tended to implant the cups in a more horizontal position (45.6 ± 6.6° [SD] and 42.7 ± 4.3°, respectively, p = 0.04). Compared to fellow, residents tended to implant the cup in a more anteverted position than the final cup version (9.6 ± 6.7° and 6.74 ± 5.6° [SD], p = 0.034). There was no statistically significant difference in cup position between attendings' free-hand and final (computer assisted) cup placement.

Accurate and consistent acetabular cup placement improves with level of training. Accurate and consistent acetabular cup version is harder to master as compared to acetabular cup inclination.