Systematic Review
The Learning Curve for Hip Arthroscopy: A Systematic Review

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Purpose

The learning curve for hip arthroscopy is consistently characterized as “steep.” The purpose of this systematic review was to (1) identify the various learning curves reported in the literature, (2) examine the evidence supporting these curves, and (3) determine whether this evidence supports an accepted number of cases needed to achieve proficiency.

Methods

The electronic databases Embase and Medline were screened for any clinical studies reporting learning curves in hip arthroscopy. Two reviewers conducted a full-text review of eligible studies and a hand search of conference proceedings and reference sections of the included articles. Inclusion/exclusion criteria were applied, and a quality assessment was completed for each included article. Descriptive statistics were compiled.

Results

We identified 6 studies with a total of 1,063 patients. Studies grouped surgical cases into “early” versus “late” in a surgeon's experience, with 30 cases being the most common cutoff used. Most of these studies used descriptive statistics and operative time and complication rates as measures of competence. Five of 6 studies showed improvement in these measures between early and late experience, but only one study proposed a bona fide curve.

Conclusions

This review shows that when 30 cases was used as the cutoff point to differentiate between early and late cases in a surgeon's experience, there were significant reductions in operative time and complication rates. However, there was insufficient evidence to quantify the learning curve and validate 30, or any number of cases, as the point at which the learning curve plateaus. As a result, this number should be interpreted with caution.

Level of Evidence

Level IV, systematic review of Level IV studies.

Section snippets

Search Strategy

Medline (1946 to July 2013) and Embase (1980 to July 2013) were searched by 2 reviewers for any clinical studies or abstracts involving learning curves in hip arthroscopy. The search strategy used combinations of the following MeSH terms: hip, arthroscopy, injury, femoroacetabular impingement, learning, learning curve, clinical competence, treatment outcome, experience, assessment, complication, and result (the Appendix provides the full search strategy). A broad search strategy was used to

Study Identification

The literature search yielded 1,023 articles after removal of duplicates. Four studies from the database search (431 patients)11, 12, 13, 14 and 2 abstracts (632 patients)15, 16 from the search of conference proceedings met the inclusion criteria and were selected for data abstraction (Fig 1). Cohen's kappa statistic measuring inter-rater agreement was 0.40 (95% confidence interval [CI], 0.31-0.50) after the title screening, 0.66 (95% CI, 0.43-0.90) after the abstract screening, and 1.0 after

Discussion

Our review found that when 30 cases was used as the cutoff number to differentiate between early and late cases in a surgeon's career, there were significant reductions in operative time and complication rates. Three of the 6 articles reported statistical significance, whereas an additional 2 studies showed trends supporting 30 cases as the number needed but did not perform any statistical analysis. However, there was insufficient evidence to quantify the learning curve and validate that 30

Conclusions

This review shows that when 30 cases was used as the cutoff number to differentiate between early and late cases in a surgeon's experience, there were significant reductions in operative time and complication rates. However, there was insufficient evidence to quantify the learning curve and validate 30 or any other number of cases as the point at which the learning curve plateaus. As a result, this number should be interpreted with caution.

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    The authors report the following potential conflict of interest or source of funding in relation to this article: M.B. has received support from Smith and Nephew, Stryker, Amgen, Zimmer, Moximed, DePuy, Eli Lily, and Bioventus.

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