title: Tunnel positioning in anterior cruciate ligament reconstruction: how long is the learning curve?
abstract: The purpose of this study is to investigate the effect of the learning curve on radiographic tunnel position. A consecutive series of the first 200 procedures of an orthopaedic surgeon over his initial 4years of independent practice were analysed for tunnel placement, based on radiographic appearance. An arthroscopic-assisted technique using patella tendon as graft material was performed in all cases. To establish femoral tunnels, a transtibial guide pin was used. The graft was secured with bioabsorbable screws. A Frik tunnel view and a strictly lateral radiograph were used to assess tunnel placements. Tunnel positioning was assessed using a computer-aided design, 2D software (Auto CAD2000(®)). To minimize measurement bias, radiographs were assessed three times or until deviations in all three measurements were less than 10%, and the three measurements were then averaged. Sagittal femoral tunnel placement improved significantly (P = 0.01) after the first 100 cases. Significant improvement (P = 0.05) in coronal femoral tunnel placement was observed after the first 75 cases. Significant improvement (P = 0.01) in sagittal tibial tunnel position was observed after the first 100 cases. Mean coronal tibial tunnel did not improve. Critical analysis in this consecutive series suggests that a caseload of approximately 100 procedures were necessary for this surgeon to refine his surgical technique beyond that acquired during formal training.
authors.affiliation: Department of Orthopaedic Surgery, Clinical Medical School, University of Queensland, Brisbane, QLD, Australia. ehohmann@optusnet.com.au
authors.forename: Erik
authors.initials: E
authors.lastname: Hohmann
authors.forename: Adam
authors.initials: A
authors.lastname: Bryant
authors.forename: Kevin
authors.initials: K
authors.lastname: Tetsworth
mesh_terms: D000704:Analysis of Variance; D016118:Anterior Cruciate Ligament / Q000000981:diagnostic imaging* / Q000601:surgery*; D001182:Arthroscopy / Q000193:education / Q000379:methods; D002983:Clinical Competence; D017076:Computer-Aided Design; D005269:Femur / Q000000981:diagnostic imaging; D006801:Humans; D007091:Image Processing, Computer-Assisted; D059032:Learning Curve; D017847:Patellar Ligament / Q000637:transplantation; D011859:Radiography; D019651:Plastic Surgery Procedures / Q000193:education* / Q000379:methods*; D018709:Statistics, Nonparametric; D013977:Tibia / Q000000981:diagnostic imaging / Q000601:surgery; D013997:Time Factors; D014463:Ultrasonography