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J Surg Educ. 2019 May 27. pii: S1931-7204(18)30861-4. doi: 10.1016/j.jsurg.2019.05.009. [Epub ahead of print]

Trauma and Orthopedic Surgery Curriculum Concordance: An Operative Learning Curve Trajectory Perspective.

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Wales PGMDE School of Surgery, Health Education and Improvement Wales, Cardiff, United Kingdom. Electronic address:
Wales PGMDE School of Surgery, Health Education and Improvement Wales, Cardiff, United Kingdom.
Department of Surgery, Morriston Hospital, Heol Maes Eglwys, Swansea, United Kingdom.



Certification of completion of training in Trauma and Orthopedic (T&O) surgery in the UK requires the demonstration of operative competence in 12 index procedures, achieved through attaining a level 4 consultant-validated procedure-based assessment (PBA). The aim of this study was to evaluate the trajectory of operative learning curves related to PBA performance with respect to operative caseload and training time.


Logbook data from consecutive 24 higher T&O trainees were compared with PBA evaluations to determine the relationship between PBA level, operative experience, training time, and indicative numbers. Learning curve gradients were calculated using trigonometry related to operative experience and training time.


A higher surgical orthopedic training program serving a single UK (Wales) Deanery.


Twenty-four consecutive higher T&O surgery trainees.


Median caseload to achieve level 4 competences ranged from 9 (interquartile range 6-12) for tension band wiring (olecranon or patella) to 101 (61-127) for arthroscopy, with significant variation between all 12 procedures (p < 0.001). Median number of PBAs to reach level 4 competences was 4 (2-6) with significant variation between procedures (p < 0.001). Median learning curve gradients to achieve level 4 competence for tension band wiring were 68.2° and 33.7° by caseload and training time respectively, compared with 12.2° and 45° for arthroscopy, with significant learning curve variation for all procedures related to caseload between first level 3 and first level 4 PBA (p < 0.001). Competence ratios were <1 (median 0.99, range 0.70-2.53) for 6 of the 12 indicative procedures.


Significant learning curve trajectory variance was observed, with discrepancies between indicative operative numbers and the point at which competence was judged achieved. Numbers of index operations to achieve certification of completion of training warrant further examination.


Medical Knowledge; Patient Care; Practice-Based Learning and Improvement; operative competence; operative learning curve; surgical training; trauma and orthopedic surgery

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