Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Nov 18, 2019; 10(11): 378-386
Published online Nov 18, 2019. doi: 10.5312/wjo.v10.i11.378
Evaluating learning and change in orthopaedics: What is the evidence-base?
Epaminondas Markos Valsamis, Mohamed Sukeik
Epaminondas Markos Valsamis, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, OX3 7LD, United Kingdom
Mohamed Sukeik, Department of Trauma and Orthopaedics, Dr. Sulaiman Al-Habib Hospital – Al Khobar, King Salman Bin Abdulaziz Rd, Al Bandariyah, Al Khobar 34423, Saudi Arabia
Author contributions: Valsamis EM and Sukeik M contributed equally to this paper with regard to conception and design of the study, literature review and analysis, drafting, critical revision, editing and approval of the final version.
Conflict-of-interest statement: No potential conflicts of interest to declare. No financial support.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Mohamed Sukeik, MD (Hons), FRCSEd (Tr&Orth), PGA, MD (Res), Consultant Hip and Knee Surgeon, Department of Trauma and Orthopaedics, Dr. Sulaiman Al-Habib Hospital – Al Khobar, King Salman Bin Abdulaziz Rd, Al Bandariyah, Al Khobar 34423, Saudi Arabia.
Telephone: +966-13-8711111
Received: March 11, 2019
Peer-review started: March 12, 2019
First decision: June 12, 2019
Revised: June 27, 2019
Accepted: September 5, 2019
Article in press: September 5, 2019
Published online: November 18, 2019

Learning and change are key elements of clinical governance and are responsible for the progression of our specialty. Although orthopaedics has been slow to embrace quality improvement, recent years have seen global developments in surgical education, quality improvement, and patient outcome research. This review covers recent advances in the evaluation of learning and change and identifies the most important research questions that remain unanswered. Research into proxies of learning is improving but more work is required to identify the best proxy for a given procedure. Learning curves are becoming commonplace but are poorly integrated into postgraduate training curricula and there is little agreement over the most appropriate method to analyse learning curve data. With various organisations promoting centralisation of care, learning curve analysis is more important than ever before. The use of simulation in orthopaedics is developing but is yet to be formally mapped to resident training worldwide. Patient outcome research is rapidly changing, with an increased focus on quality of life measures. These are key to patients and their care. Cost-utility analysis is increasingly seen in orthopaedic manuscripts and this needs to continue to improve evidence-based care. Large-scale international, multi-centre randomised trials are gaining popularity and updated guidance on sample size estimation needs to become widespread. A global lack of surgeon equipoise will need to be addressed. Quality improvement projects frequently employ interrupted time-series analysis to evaluate change. This technique’s limitations must be acknowledged, and more work is required to improve the evaluation of change in a dynamic healthcare environment where multiple interventions frequently occur. Advances in the evaluation of learning and change are needed to drive improved international surgical education and increase the reliability, validity, and importance of the conclusions drawn from orthopaedic research.

Keywords: Learning, Change, Quality improvement, Orthopaedics, Surgical education

Core tip: Learning and change are integral to clinical governance. Despite orthopaedics being slow to embrace quality improvement, recent years have seen global improvements in the field. This review covers various aspects of learning and change including: proxies of learning, learning curve analysis, simulation, outcome measures, retrospective and prospective studies as well as time-series analysis. It summarises the current evidence-base and identifies research questions that remain unanswered.