Does a "July Effect" Exist for Fellowship Training in Total Hip and Knee Arthroplasty?

J Arthroplasty. 2020 May;35(5):1208-1213. doi: 10.1016/j.arth.2019.12.045. Epub 2020 Jan 3.


Background: The hypothetical association between health-care errors and the transition of the medical academic year has been termed the "July effect." Data supporting its existence are conflicting, particularly in orthopedic surgery, and prior studies have inappropriately grouped fellows with resident trainees. No studies to date have examined whether a training initiation effect exists among surgical fellows in adult reconstructive orthopedics.

Methods: This is a level IV retrospective cohort study reviewing 15,650 primary hip and knee arthroplasties performed from 2006 to 2016 at a single institution. Forty arthroplasty fellows were trained during this 10-year period. Primary outcome measures included intraoperative complications, additional procedures, revisions, and nonoperative complications within 90 days of surgery. These complication rates were analyzed by quarter of academic year and by temporal progression through three-month fellowship rotations.

Results: There were no differences in intraoperative complication, revision, or nonoperative complication rates between any academic quarter. There was a single statistically lower rate of additional procedures in the third quarter (1.2%) than in the fourth quarter (1.8%, P = .04). The most common complication in this subset was wound dehiscence for patients undergoing hip arthroplasty and stiffness for patients undergoing knee arthroplasty. There was no difference in complication rates during the first, second, or third month as fellows progressed through a single rotation.

Conclusion: This study does not support the existence of a training-initiation effect among fellows in adult hip and knee reconstruction. Graduated autonomy can be safely employed in a fellowship program without negatively impacting patient outcomes, ensuring the continued high-caliber training of future surgeons.

Keywords: July effect; complications; fellowship education; hip arthroplasty; knee arthroplasty.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Arthroplasty, Replacement, Hip* / adverse effects
  • Arthroplasty, Replacement, Knee* / adverse effects
  • Fellowships and Scholarships
  • Humans
  • Internship and Residency*
  • Orthopedics* / education
  • Retrospective Studies