Practice Patterns of Adult Reconstruction Fellowship–Trained Surgeons: Current Trends and Evolution of Training From 1986 to 2022

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Abstract
Introduction: Total joint arthroplasty (TJA) is evolving with new technologies and techniques introduced in fellowship training, but the effect on surgeons' future practices remains unclear. We assessed current practice patterns and influential factors among fellowship-trained arthroplasty surgeons. Methods: An electronic survey was sent to all currently practicing surgeons (n = 90) who had completed a high-volume adult reconstruction fellowship at a single tertiary academic center from 1986 to 2022. The survey consisted of 73 questions regarding surgeon and practice characteristics for primary and revision total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty. Data were tabulated and analyzed in REDCap software. Results: The survey was completed by 53 surgeons (59%): 46% had been in practice for 0 to 5 years, 32% for 6 to 10 years, and 21% for 11 to 20 years. Overall, 81% performed at least 100 THAs, and 77% performed at least 150 TKAs annually. Revision TJA constituted 0% to 20% of surgical practice for 70% of surgeons, whereas 30% performed revision TJA in 21% to 40% of cases. The most common approach for THA was direct anterior (28/53, 53%), followed by posterior (22/53, 42%). Fellowship experience was the most influential factor on the choice of THA approach (57%), as well as on the choice of THA (64%) and TKA (57%) implants. Among surgeons with access to robots, 52% did not perform any robotic THAs, whereas 27% performed more than 80% of their THAs robotically. By contrast, 64% of surgeons performed more than 80% of their primary TKAs robotically, and only 13% did no robotic TKAs despite having access to a robot. Conclusion: Fellowship experience was the primary factor influencing approach and implant choices in both THA and TKA, highlighting its notable effect on shaping trainees' future practices. Therefore, fellowship programs should offer exposure to diverse technologies and techniques to enable informed decision making.

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