JOA - 2026-05-13 - Journal Article
Impact of Fellow Involvement on Patient Outcomes in Total Hip and Knee Arthroplasty.
Zabawa L, Baker N, Manganello C, Pfeil A, Cardenas J, Gladnick B
Topics
Key Takeaway
Fellow involvement in primary TKA produced no significant difference in operative time (54.0 vs. 56.4 min, P=0.131), and a 9-minute THA time penalty during the first fellowship rotation resolved by the second rotation (78.3 vs. 75.4 min, P=0.149).
Summary Depth
Choose how much analysis to show on this article page.
Summary
This single-institution retrospective cohort compared operative efficiency and PROMs in primary THA and TKA performed with versus without fellow involvement over a 20-month period. TKA operative times were equivalent between groups; THA showed a statistically significant 9-minute increase with fellow involvement in the first rotation only, which normalized by the second rotation. No differences were detected in 90-day readmissions, SSI, revision rates, or any PROM including 1-year HOOS JR and KOOS JR.
Key Limitation
The retrospective design cannot exclude confounding from case selection bias, as attending surgeons may have preferentially assigned less complex cases to fellows, artificially equalizing outcomes.
Original Abstract
BACKGROUND
Total joint arthroplasty (TJA) fellowships are increasingly common for surgical specialization, yet evidence regarding the impact of fellow involvement on patient-reported outcome measures (PROMs) and operative efficiency remains limited. This study evaluated if an arthroplasty fellow affects clinical outcomes or surgical theater efficiency compared to an attending surgeon operating alone.
METHODS
A retrospective cohort study was conducted on 450 patients who underwent elective primary unilateral total hip arthroplasty (THA; n = 251) or total knee arthroplasty (TKA; n = 199) between August 2023 and March 2025 at a single institution. Patients were divided into two groups: those where a fellow was actively involved and those performed by the attending surgeon alone. The primary outcomes included surgical efficiency (total tourniquet or operative time) and postoperative clinical outcomes, including 90-day readmissions, surgical site infections (SSI), and revision rates. The secondary outcomes included PROMs (Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR), Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR), Patient-Reported Outcomes Measurement Information System (PROMIS), and Visual Analog Scale (VAS)) collected preoperatively and up to one year postoperatively.
RESULTS
For TKA, operative times were comparable (54.0 non-fellow versus 56.4 minutes for fellow; P = 0.131). In THA, fellow involvement initially increased operative time during the first rotation (84.5 versus 75.4 minutes; P = 0.012), but this difference resolved by the second rotation (78.3 minutes; P = 0.149). There were no statistically significant differences observed in any PROMs, including 1-year HOOS JR (P = 0.115) and KOOS JR (P = 0.869), or in resting and active VAS pain scores at any time point (P > 0.05).
CONCLUSION
Fellow involvement in primary TJA does not compromise operative efficiency or patient outcomes. In conclusion, our data support the continued mentorship of fellows within high-volume practices without compromising clinical outcomes or senior surgeon workflow.