Longer Operative Time Is Associated With Increased Adverse Events After Anterior Cervical Diskectomy and Fusion: 15-Minute Intervals Matter

Are all Cages Created Equal? Analysis of Cervical Cage Malfunctions Using FDA MAUDE Database

STUDY DESIGN

Retrospective case series.

OBJECTIVE

To characterize failure rates of cervical cages based on manufacturer and design characteristics using the nationwide database of reported malfunctions.

BACKGROUND

The Food and Drug Administration (FDA) aims to ensure the safety and efficacy of cervical interbody implants postimplantation; however, intraoperative malfunctions may be overlooked.

MATERIALS AND METHODS

The FDA's Manufacturer and User Facility Device Experience database was queried for reports of cervical cage device malfunctions from 2012 to 2021. Each report was categorized based on the failure type, implant design, and manufacturer. Two market analyses were performed. First, "failure-to-market share indices" were generated by dividing the number of failures per year for each implant material by its yearly US market share in cervical spine fusion. Second, "failure-to-revenue indices" were calculated by dividing the total number of failures per year for each manufacturer by their approximate yearly revenue from spinal implants in the US. Outlier analysis was performed to generate a threshold value above which failure rates were defined as greater than the normal index.

RESULTS

In total, 1336 entries were identified, and 1225 met the inclusion criteria. Of these, 354 (28.9%) were cage breakages, 54 (4.4%) were cage migrations, 321 (26.2%) were instrumentation-related failures, 301 (24.6%) were assembly failures, and 195 (15.9%) were screw failures. Poly-ether-ether-ketone implants had higher failure by market share indices for both migration and breakage compared with titanium. Upon manufacturer market analysis, Seaspine, Zimmer-Biomet, K2M, and LDR exceeded the failure threshold.

CONCLUSION

The most common cause of implant malfunction was breakage. Poly-ether-ether-ketone cages were more likely to break and migrate compared with titanium ones. Many of these implant failures occurred intraoperatively during instrumentation, which underscores the need for FDA evaluation of these implants and their accompanying instrumentation under the appropriate loading conditions before commercial approval.

Ensuring Safety While Achieving Beauty: An Evidence-Based Approach to Optimizing Mastectomy and Autologous Breast Reconstruction Outcomes in Patients with Obesity

BACKGROUND

Although obesity has previously been associated with poor outcomes after mastectomy and breast reconstruction, its impact across the WHO obesity classification spectrum and the differential effects of various optimization strategies on patient outcomes have yet to be delineated. We sought to examine the impact of WHO obesity classification on intraoperative surgical and medical complications, postoperative surgical and patient-reported outcomes of mastectomy and autologous breast reconstruction, and delineate outcomes optimization strategies for obese patients.

STUDY DESIGN

This is a review of consecutive patients who underwent mastectomy and autologous breast reconstruction from 2016 to 2022. Primary outcomes were complication rates. Secondary outcomes were patient-reported outcomes and optimal management strategies.

RESULTS

We identified 1,640 mastectomies and reconstructions in 1,240 patients with mean follow-up of 24.2 ± 19.2 months. Patients with class II/III obesity had higher adjusted risk of wound dehiscence (odds ratio [OR] 3.20; p < 0.001), skin flap necrosis (OR 2.60; p < 0.001), deep venous thrombosis (OR 3.90; p < 0.033), and pulmonary embolism (OR 15.3; p = 0.001) than nonobese patients. Obese patients demonstrated significantly lower satisfaction with breasts (67.3 ± 27.7 vs 73.7 ± 24.0; p = 0.043) and psychological well-being (72.4 ± 27.0 vs 82.0 ± 20.8; p = 0.001) than nonobese patients. Unilateral delayed reconstructions were associated with independently shorter hospital stay (β -0.65; p = 0.002) and lower adjusted risk of 30-day readmission (OR 0.45; p = 0.031), skin flap necrosis (OR 0.14; p = 0.031), and pulmonary embolism (OR 0.07; p = 0.021).

CONCLUSIONS

Obese women should be closely monitored for adverse events and lower quality of life, offered measures to optimize thromboembolic prophylaxis, and advised on the risks and benefits of unilateral delayed reconstruction.

Risk Factors for Unexpected Admission Following Outpatient Rotator Cuff Repair: A National Database Study

Introduction  Rotator cuff repair (RCR) procedures are some of the most common orthopaedic surgeries performed in the United States. Compared to other orthopaedic procedures, RCRs are of relatively low morbidity. However, complications may arise that result in readmission to an inpatient healthcare facility. The purpose of this study is to identify the demographics and risk factors associated with unplanned 30-day readmission after RCR. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients that underwent elective RCR from 2015-2019. Univariate and multivariate analyses were utilized to assess patient demographics, comorbidities, and peri-operative variables predicting unplanned 30-day readmission. Results Of the identified 45,548 patients that underwent RCR, 597 (1.3%) required readmission within 30 days of the procedure. Multivariate analysis identified male sex (OR 1.36, 95% CI: 1.10, 1.67), hypertension (OR 1.29, 95% CI:1.03, 1.62), chronic obstructive pulmonary disease (COPD) (OR 2.07, 95% CI: 1.46, 2.93), American Society of Anesthesiologists (ASA) Class III (OR 1.85, 95% CI: 1.07, 3.18), ASA Class IV (OR 5.38, 95% CI: 2.70, 10.72), and total operative time (OR 1.002, 95% CI: 1.000, 1.004) as independent risk factors for unplanned readmission. Conclusion Unplanned 30-day readmission after RCR is infrequent. However, certain patients may be at increased risk for unplanned 30-day admission to an inpatient facility. This study confirmed male sex, COPD, hypertension, ASA Class III, ASA Class IV, and total operative time to be independent risk factors for readmission following outpatient RCR.

Late Retropharyngeal and Parapharyngeal Abscess in Patients with a History of Anterior Cervical Discectomy and Fusion

OBJECTIVE

Anterior cervical discectomy and fusion is a common procedure performed by spine surgeons with rare complications and high treatment success. Late presentation of retropharyngeal abscess in patients with a history of anterior cervical discectomy and fusion is rare but can have devastating consequences. There is a paucity of data to guide medical and surgical management of retropharyngeal abscess in these patients.

METHODS

We discuss 7 patients who presented to our institution with a late retropharyngeal abscess after having a history of anterior cervical discectomy and fusion. A review and description of the current literature regarding treatment and outcomes is described.

RESULTS

Seven patients presented to our institution with a retropharyngeal abscess ranging from 10 months to 7 years after undergoing anterior cervical discectomy and fusion. All patients received at least a 6-week course of appropriate intravenous antibiotics. Only one patient had their initial ACDF instrumentation removed at the time of presentation for the abscess. Four out of the 7 patients were treated with irrigation and debridement in addition to intravenous antibiotics, whereas 3 patients were treated with no surgery and intravenous antibiotics alone. All patients were asymptomatic at final follow up.

CONCLUSIONS

Late retropharyngeal abscess after anterior cervical discectomy and fusion is a rare complication. Surgical management should be considered along with long term antibiotics. Removal of implants may not be necessary for infection resolution. Antibiotic treatment alone may be indicated for patients who are not septic, do not have airway compromise, or and can be considered for poor surgical candidates.

Incidence, Risk Factors, and Subsequent Complications of Postoperative Hematomas Requiring Reoperation After Primary Total Hip Arthroplasty

Background

Studies analyzing the incidence and clinical implications of postoperative hematomas after total hip arthroplasty (THA) remain limited. The purpose of the present study was to use the National Surgical Quality Improvement Program (NSQIP) dataset to determine rates, risk factors, and subsequent complications of postoperative hematomas requiring reoperation after primary THA.

Methods

Study population included patients who underwent primary THA (CPT code: 27130) from 2012-2016 recorded in NSQIP. Patients who developed a hematoma requiring reoperation in the 30-day postoperative period were identified. Multivariate regressions were created to identify patient characteristics, operative variables, and subsequent complications that were associated with a postoperative hematoma requiring reoperation.

Results

Among the 149,026 patients who underwent primary THA, 180 (0.12%) developed a postoperative hematoma requiring reoperation. Risk factors included body mass index (BMI) ≥ 35 (relative risk [RR]: 1.83, P = .011), American Society of Anesthesiologists (ASA) class ≥3 (RR: 2.11, P < .001), and history of bleeding disorder (RR: 2.71, P < .001). Associated intraoperative characteristics were an operative time ≥100 minutes (RR: 2.03, P < .001) and use of general anesthesia (RR: 1.41, P = .028). Patients developing a hematoma requiring reoperation were at higher risk of subsequent deep wound infection (RR: 21.57, P < .001), sepsis (RR: 4.3, P = .012), and pneumonia (RR: 3.69, P = .023).

Conclusions

Surgical evacuation for a postoperative hematoma was performed in about 1 in 833 cases of primary THA. Several nonmodifiable and modifiable risk factors were identified. Given the 21.6 times increased risk of subsequent deep wound infection, select, at-risk patients may benefit from closer monitoring for signs of infection.

Impact of Prolonged Operative Duration on Postoperative Symptomatic Venous Thromboembolic Events After Thoracolumbar Spine Surgery

OBJECTIVE

To determine the effect of operative duration on the rate of postoperative symptomatic venous thromboembolic (VTE) events in patients undergoing thoracolumbar spine fusion.

METHODS

We identified all thoracolumbar spine fusion patients between 2012 and 2021. Operative duration was defined as time from skin incision to skin closure. A 1:1 propensity match was conducted incorporating patient and surgical characteristics. Logistic regression was performed to assess predictors of postoperative symptomatic VTE events. A receiver operating characteristic curve was created to determine a cutoff time for increased likelihood of VTE.

RESULTS

We identified 101 patients with VTE and 1108 patients without VTE. Seventy-five patients with VTE were matched to 75 patients without VTE. Operative duration (339 vs. 262 minutes, P = 0.010) and length of stay (5.00 vs. 3.54 days, P = 0.008) were significantly longer in patients with a VTE event. Operative duration was an independent predictor of VTE on multivariate regression (odds ratio: 1.003, 95% confidence interval: 1.001-1.01, P = 0.021). For each additional hour of operative duration, the risk of VTE increased by 18%. A cutoff time of 218 minutes was identified (area under the curve [95% confidence interval] = 0.622 [0.533-0.712]) as an optimal predictor of increased risk for a VTE event.

CONCLUSIONS

Operative duration significantly predicted symptomatic VTE, especially after surgical time cutoff of 218 minutes. Each additional hour of operative duration was found to increase VTE risk by 18%. We also identify the impact of VTE on 90-day readmission rates, suggesting significantly higher costs and opportunity for hospital acquired conditions, in line with prior literature.

Effect of Fellow Involvement and Experience on Patient Outcomes in Spine Surgery

INTRODUCTION

Investigations in spine surgery have demonstrated that trainee involvement correlates with increased surgical time, readmissions, and revision surgeries; however, the specific effects of spine fellow involvement remain unelucidated. This study aims to investigate the isolated effect of fellow involvement on surgical timing and patient-reported outcomes measures (PROMs) after spine surgery and evaluate how surgical outcomes differ by fellow experience.

METHODS

All patients aged 18 years or older who underwent primary or revision decompression or fusion for degenerative diseases and/or spinal deformity between 2017 and 2019 at a single academic institution were retrospectively identified. Patient demographics, surgical factors, intraoperative timing, transfusion status, length of stay (LOS), readmissions, revision rate, and preoperative and postoperative PROMs were recorded. Surgeries were divided based on spine fellow participation status and occurrence in the start or end of fellowship training. Univariate and multivariate analyses compared outcomes across fellow involvement and fellow experience groups.

RESULTS

A total of 1,108 patients were included. Age, preoperative diagnoses, number of fusion levels, and surgical approach differed markedly by fellow involvement. Fellow training experience groups differed by patient smoking status, preoperative diagnosis, and surgical approach. On univariate analysis, spine fellow involvement was associated with extended total theater time, induction start to cut time, cut to close time, and LOS. Increased spine fellow training was associated with reduced cut to close time and LOS. On regression, fellow involvement predicted cut to close extension while increased fellow training experience predicted reduction in cut to close time, both independent of surgical factors and assisting residents or physician assistants. Transfusions, readmissions, revision rate, and PROMs did not differ markedly by fellow involvement or experience.

CONCLUSION

Spine fellow participation predicted extended procedural duration. However, the presence of a spine fellow did not affect long-term postoperative outcomes. Furthermore, increased fellow training experience predicted decreased procedural time, underscoring a learning effect.

AVAILABILITY OF DATA AND MATERIAL

The data sets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

LEVEL OF EVIDENCE

Level 3.

The impact of case order and intraoperative staff changes on spine surgical efficiency

BACKGROUND CONTEXT

Despite concerted efforts toward quality improvement in high-volume spine surgery, there remains concern that increases in case load may compromise the efficient and safe delivery of surgical care. There is a paucity of evidence to describe the effects of spine case order and operating room (OR) team structure on measures of intraoperative timing and OR efficiency.

PURPOSE

This study aims to determine if intraoperative staff changes and surgical case order independently predict extensions in intraoperative timing after spinal surgery for spondylotic diseases.

STUDY DESIGN/ SETTING

Retrospective cohort analysis PATIENT SAMPLE: All patients over age 18 who underwent primary or revision decompression and/or fusion for degenerative spinal diseases between 2017 to 2019 at a single academic institution were retrospectively identified. Exclusion criteria included absence of descriptive data and intraoperative timing parameters as well as surgery for traumatic injury, infection, and malignancy.

OUTCOME MEASURES

Intraoperative timing metrics including total theater time, wheels in to induction, induction start to cut, cut to close, and close to wheels out. Postoperative outcomes included length of hospital stay and 90-day hospital readmissions.

METHODS

Surgical case order and intraoperative changes in staff (circulator and surgical scrub nurse or technician) were determined. Patient demographics, surgical factors, intraoperative timing and postoperative outcomes were recorded. Extensions in each operative stage were determined as a ratio of the actual duration of the parameter divided by the predicted duration of the parameter. Univariate and multivariate analyses were performed to compare outcomes within case order and staff change groups.

RESULTS

A total of 1,108 patients met the inclusion criteria. First, second, and third start cases differed significantly in intraoperative extensions of total theater time, wheels in to induction, induction start to cut, cut to close, and close to wheels out. On regression, decreasing case order predicted extension in wheels in to induction time. Surgeries with intraoperative staff changes were associated with increases in total theater time, induction start to cut time, cut to close time, close to wheels out time, and length of hospital stay. Switch in primary circulator predicted extended theater time and cut to close time. Relief of primary circulator or scrub predicted extended total theater time, induction start to cut time, cut to close time, and close to wheels out time.

CONCLUSIONS

Intraoperative staff change in spine surgery independently predicted extended operative duration. However, higher case order was not significantly associated with procedural time.

Comparison of Endoscopic Discectomy Versus Non-Endoscopic Discectomy for Symptomatic Lumbar Disc Herniation: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review.

OBJECTIVE

The authors aimed to systematically compare the effectiveness and safety of endoscopic discectomy (ED) with non-endoscopic discectomy (NED) for treatment of symptomatic lumbar disc herniation (LDH).

METHODS

A systematic search was performed on PubMed, EMBASE, the Cochrane Library and China National Knowledge Infrastructure for randomized controlled trial from inception until August 13, 2020. Trials which investigated multiple operative approaches on lumbar disc herniation were identified without language restrictions.

RESULTS

In total, 25 trials involving 2258 patients with symptomatic LDH were included. Twenty trials performed the comparison between ED and NED. Five trials performed the comparison between percutaneous endoscopic transforaminal discectomy (PETD) and percutaneous endoscopic interlaminar discectomy (PEID). The operative time of micro-endoscopic discectomy (MED) was longer than open discectomy (OD). The length of hospital stay of percutaneous endoscopic lumbar discectomy (PELD) was shorter than fenestration discectomy (FD). Significant differences in intraoperative blood loss volumes were found between PELD with FD and MED with OD. The complication rate of PELD was lower than FD (PELD: 4.3%; FD: 14.6%) and the complication rate of full-endoscopic discectomy (FE) was lower than microscopic discectomy (MD) (FE: 13.4%; MD: 32.1%).

CONCLUSIONS

PELD and FE have the advantage of limiting intraoperative damages. ED and NED can be both considered sufficient to achieve good clinical outcomes. PETD and PEID are able to achieve similar results but the learning curve of PETD was steeper. More independent high-quality RCTs with sufficiently large sample sizes performing cost-effectiveness analyzes are needed.

Learning Curve and Initial Outcomes of Full-Endoscopic Posterior Lumbar Interbody Fusion

Study Design

This was a retrospective cohort study.

Objective

We evaluated the feasibility, safety, and accuracy of full-endoscopic posterior lumbar interbody fusion (FE-PLIF) by assessing the learning curve and initial clinical outcomes.

Summary of Background Data

Low back pain is one of the crucial medical conditions worldwide. FE-PLIF has been reported to be a minimally invasive method to treat mechanical low back pain, but there lacks a thorough evaluation on this new technique.

Methods

The patients were divided into three groups in the order of operating date, implying that Group A consisted of the initial 12 cases, Group B the subsequent 12 cases, and Group C the last 12 cases. The data of patients were reviewed for gender, age, preoperative symptoms, satisfaction, as well as clinical outcomes demonstrated by visual analog scale (VAS). The operative time and intraoperative fluoroscopy were recorded to demonstrate the learning curve and the extent of radiographic exposure. Statistical significance was set at a p &lt; 0.05 (two-sided).

Results

The patients enrolled in this study were followed up at an average of 1.41 ± 0.24 years. Overall, patients were satisfied with the surgery. The average number of intraoperative fluoroscopy was 6.97 ± 0.74. A significant improvement was observed in the VAS of both lumbar pain and leg pain. The overall fusion rate was 77.7%. Complications were reported in two patients in Group A, one in Group B, and none in Group C. The average operative time showed a trend of gradual decline. The learning curve was characterized using a cubic regression analysis as y = –27.07x + 1.42x2–0.24x3 + 521.84 (R2 = 0.617, p = 0.000).

Conclusions

FE-PLIF is an effective and safe method for treating low back pain caused by short-segmental degenerative diseases. The learning curve of this technique is steep at the initial stage but acceptable and shows great potential for improvement.

Establishing a Reference Procedure Length for Anterior Cervical Fusions: The Role for Standards in Surgical Process Improvement

Surgical process improvement strategies are increasingly being applied to specific procedures to improve value. A critical step in any process improvement strategy is the identification of performance benchmarks. Procedure length is a performance benchmark for anterior cervical discectomy and fusion (ACDF) procedures; therefore, we sought to establish reference procedure lengths for 1-level, 2-level, and 3-level ACDFs at both teaching and non-teaching institutions and to describe methods for using this information to advance surgical process improvement initiatives. We performed a retrospective analysis of consecutive ACDFs performed at a resident teaching institution (RT) and a non-teaching institution (NT) for all 1-level, 2-level, and 3-level ACDFs. Mean case lengths and patient outcomes were calculated for individual surgeons and institutions. After limiting cases to 1-level, 2-level, and 3-level ACDFs and applying all exclusion criteria, 991 cases at the RT institution and 131 cases at the NT institution (a total of 1122 cases) were available for analysis. The mean (SD) procedure length for 1-level, 2-level, and 3-level ACDFs at the RT versus NT institutions were 121.9 min (36.3 min) and 73.6 min (29.7 min) (p<0.001), 172.7 min (44.8 min) and 112.0 min (43.0 min) (p<0.001), and 218.3 min (54.9 min) and 167.6 min (54.2 min) (p<0.001), respectively. Thirty-day outcomes were the same between institutions, except that the RT institution had a shorter mean hospital length of stay for 2-level ACDFs (1.6 days versus 2.9 days, p=0.001). This study is the first to attempt to establish a standard reference procedure length for 1-level, 2-level, and 3-level ACDFs. These data can guide efforts in surgical process improvement.

Three-dimensional high-definition exoscope (Kestrel View II) in anterior cervical discectomy and fusion: a valid alternative to operative microscope-assisted surgery

BACKGROUND

Operative microscope (OM) has greatly advanced modern spine surgery, but remains limited by several drawbacks. Therefore, a three-dimensional (3D) high-definition (HD) exoscope (EX) (Kestrel View II, Mataka Kohli, Japan) system has been developed and used as an alternative to the OM. The aim of this study was to assess and compare the perioperative data and clinical outcomes of anterior cervical discectomy and fusion (ACDF) procedure with either an EX or OM.

METHODS

Forty-eight patients with cervical spondylotic myelopathy (CSM) underwent ACDF assisted by the EX or OM between January 2019 and December 2019. We collected and compared data on operative time, intraoperative bleeding, postoperative hospitalization stay, complications, and clinical outcomes between the two groups. The clinical outcomes were evaluated by using visual analogue scale (VAS) scores, Japanese Orthopedic Association (JOA) scores, the recovery rate of JOA scores, and Odom criteria.

RESULTS

The operative time in the EX group was significantly shorter than that in the OM group (P < 0.05). The VAS and JOA scores were significantly improved in both groups after surgery (P < 0.05). In addition, the VAS scores in the EX group were significantly lower than those in the OM group at 1 week postoperatively (P < 0.05). The good-to-excellent outcome rates were 90.48 and 88.89% in the EX group and OM group, respectively, whereas the complication occurrence rates of the EX group and OM group were 4.76 and 11.11%, respectively.

CONCLUSIONS

EX-assisted and OM-assisted ACDF resulted in similar clinical outcomes for CSM, while EX-assisted surgery may be related to a short operative time and fewer complications.

Longer operative time associated with prolonged length of stay, non-home discharge and transfusion requirement after anterior cervical discectomy and fusion: an analysis of 24,593 cases

BACKGROUND

Prolonged operative time of single-level ACDF has been associated with adverse postoperative outcomes. The current literature does not contain a comprehensive quantitative description of these associations PURPOSE: This study characterized the associations between single-level anterior cervical discectomy and fusion(ACDF) operative time and (1)30-day postoperative healthcare utilization, and (2)the incidence of local wound complications, need for transfusion and mechanical ventilation.

DESIGN/SETTING

Retrospective database analysis PATIENT SAMPLE: The American College of Surgeons National Surgical Quality Improvement Program(ACS-NSQIP) database was queried for single-level ACDF cases(2012-2018) using current procedural terminology codes. A total of 24,593 cases were included.

OUTCOME MEASURES

Primary outcomes included healthcare utilization(lengths of stay[LOS], discharge dispositions, 30-day readmissions, and reoperations) per operative time category. The secondary outcome was the incidence of wound complications, blood transfusion and need for ventilation per operative time category.

METHODS

Multivariate regression determined operative time categories associated with increased risk while adjusting for patient demographics and comorbidities. Predictive spline regression models visualized the associations.

RESULTS

Compared to the reference operative time of 81-100-minutes, the 101-120-minute category was associated with higher odds of LOS >2 days(OR:1.36,95%CI(1.18-1.568);p<.001) and non-home discharge(OR:1.341,95%CI(1.081-1.664);p=.008). Three-times greater odds of LOS >2 days(OR:3.367,95%CI(2.719-4.169); p<.001) and twice the odds of non-home discharge(OR:2.174,95%CI(1.563-3.022);p<.001) were detected at 181-200-minutes. The highest operative time category(≥221 minutes) was associated with the highest odds of LOS>2 days(OR:4.838,95%CI(4.032-5.804);p<.001), non-home discharge(OR:2.687,95%CI(2.045-3.531);p<.001) and reoperation(OR:1.794,95%CI(1.094-2.943);p=.021). Patients within the 201-220 and the ≥221-minute categories exhibited a significant association with greater odds of transfusion(OR:8.57,95%CI(2.321-31.639);p<.001, and OR:11.699, 95%CI(4.179-32.749);p=.001, respectively). Spline regression demonstrated that the odds of LOS >2 days, non-home discharge disposition, reoperation and bleeding requiring transfusion events began to rise, starting at 94, 91.6, 91.6, and 93.3 minutes of operative time, respectively.

CONCLUSION

This study demonstrated that prolonged operative time is associated with increased odds of healthcare utilization and transfusion after single-level ACDF. Operative times greater than 91 minutes may carry higher odds of postoperative complications.

The safety and accuracy of robot-assisted pedicle screw internal fixation for spine disease: a meta-analysis

Aims

The aim of this study was to systematically compare the safety and accuracy of robot-assisted (RA) technique with conventional freehand with/without fluoroscopy-assisted (CT) pedicle screw insertion for spine disease.

Methods

A systematic search was performed on PubMed, EMBASE, the Cochrane Library, MEDLINE, China National Knowledge Infrastructure (CNKI), and WANFANG for randomized controlled trials (RCTs) that investigated the safety and accuracy of RA compared with conventional freehand with/without fluoroscopy-assisted pedicle screw insertion for spine disease from 2012 to 2019. This meta-analysis used Mantel-Haenszel or inverse variance method with mixed-effects model for heterogeneity, calculating the odds ratio (OR), mean difference (MD), standardized mean difference (SMD), and 95% confidence intervals (CIs). The results of heterogeneity, subgroup analysis, and risk of bias were analyzed.

Results

Ten RCTs with 713 patients and 3,331 pedicle screws were included. Compared with CT, the accuracy rate of RA was superior in Grade A with statistical significance and Grade A + B without statistical significance. Compared with CT, the operating time of RA was longer. The difference between RA and CT was statistically significant in radiation dose. Proximal facet joint violation occurred less in RA than in CT. The postoperative Oswestry Disability Index (ODI) of RA was smaller than that of CT, and there were some interesting outcomes in our subgroup analysis.

Conclusion

RA technique could be viewed as an accurate and safe pedicle screw implantation method compared to CT. A robotic system equipped with optical intraoperative navigation is superior to CT in accuracy. RA pedicle screw insertion can improve accuracy and maintain stability for some challenging areas.Cite this article: Bone Joint Res 2020;9(10):653-666.

Thirty-Day Outcomes following Upper Extremity Flap Reconstruction

Introduction  Flap reconstructions of upper extremity defects are challenging procedures. It is important to understand the surgical outcomes of upper extremity flap reconstruction, as well as associations between preoperative/perioperative variables and complications.

Materials and Methods  The National Surgical Quality Improvement Program (NSQIP) database was queried for patients from 2005 to 2016 who underwent flap reconstruction of an upper extremity defect. Patient and perioperative variables were collected for identified patients and assessed for associations with rates of any complication and major complications.

Results  On multivariate analysis, American Society of Anesthesiologists (ASA) classification >2, bleeding disorder, preoperative steroid use, free flap reconstruction, wound classification other than clean, and nonplastic surgeon specialty were independently associated with any complications. Bleeding disorder, ASA classification >2, male gender, wound classification other than clean, and preoperative anemia were independently associated with major complications. Free flap reconstruction was associated with increased length of stay, operative time, any complications, transfusions, and unplanned reoperations.

Conclusion  There is an association between complications in patients undergoing upper extremity free flap reconstruction and ASA classification >2, preoperative anemia, preoperative steroid use, bleeding disorders, and contaminated wounds. Male patients may require more thorough counseling in activity restriction following reconstruction. Free flaps for upper extremity reconstruction will require increased planning to reduce the chance of complications.

Total Ankle Arthroplasty Is Safer Than Total Hip and Knee Arthroplasty in the Early Postoperative Period

BACKGROUND

Total hip and knee arthroplasty (THA and TKA) are performed more commonly than total ankle arthroplasty (TAA), so patients and the orthopaedic community are more familiar with the likelihood of complications after THA and TKA than after TAA. The present study places early complication rates after TAA in the context of those after THA and TKA.

METHODS

Patients who underwent TAA, THA, or TKA during 2006 to 2016 as part of the National Surgical Quality Improvement Program were identified. Multivariate regression was used to compare procedures with adjustment for baseline and anesthesia characteristics.

RESULTS

One hundred thirty-eight thousand three hundred twenty-five patients underwent THA, 223,587 TKA, and 839 TAA. The total complication rate was lower for TAA (2.98%) compared with THA (4.92%, P = 0.011) and TKA (4.56%, P = 0.049). Similarly, the rate of blood transfusion was lower for TAA (0.48%) compared with THA (9.66%) and TKA (6.44%, P < 0.001 for each). The rate of additional surgery was lower for TAA compared with THA (0.48% versus 1.79%, P = 0.007). Finally, the rate of readmission was lower for TAA (1.45%) compared with THA (3.66%, P = 0.002) and TKA (3.40%, P = 0.005).

DISCUSSION

Patients can be counseled that relative to THA and TKA, TAA is safer in the perioperative period, with lower rates of adverse events, blood transfusion, additional surgery, and hospital readmission.

Influence of Operative Time in the Results of Infrainguinal Bypass for Chronic Limb Threatening Ischemia

BACKGROUND

An increased operative time (OT) has been associated with a higher rate of adverse outcomes after several surgical procedures although scarce evidence exists for infrainguinal bypass surgery (IBS) and its impact beyond the postoperative period. The aim of this study was to define surgical characteristics related to a prolonged OT in IBS for chronic limb threatening ischemia and its influence on postoperative and 1-year outcomes.

MATERIALS AND METHODS

Retrospective study of 249 consecutive patients (mean age 72.4 years, 73.1% male) undergoing IBS for CLI between 2008 and 2018. The characteristics related to the duration of surgery and its impact on outcome were assessed with a multiple linear regression and a multivariate logistic regression, respectively.

RESULTS

Interventions associated with a prolonged OT included the bypass to a below-the-knee artery (additional 36 min, p = 0.002), the need for an alternative vein or a hybrid PTFE-vein graft (additional 37 min, p = 0.02) and inflow associated procedures (additional 47 min, p < 0.001). OT was associated with a higher rate of postoperative complications (OR for each additional 30 min 1.123, 95% CI 1.021-1.234) and need for a sociosanitary facility at discharge (OR 1.143, 95% CI 1.033-1.265). At 1-year of follow-up, OT was related to a higher major amputation rate (OR 1.201, 95% CI 1.036-1.393) and non-significantly to mortality (OR 1.125, 95% CI 0.999-1.268).

CONCLUSIONS

A prolonged OT is a risk factor for adverse outcomes after IBS that extends beyond the immediate postoperative period. Further research is needed to evaluate how an expected high OT might influence decision-making.

Meta-analysis of the effect of antithrombotic drugs on perioperative bleeding in BPH surgery

Effects of antithrombotic agents on the bleeding risk after transurethral resection of the prostate (TURP) were assessed in patients with benign prostatic hyperplasia (BPH). Controlled clinical trials on the effects of perioperative anticoagulant therapy on postoperative bleeding in BPH patients published during January 1990 and February 2019 were searched in PubMed, Embase and the Cochrane Library. Two independent reviewers screened the studies according to the inclusion and exclusion criteria, extracted the data, evaluated the quality, and conducted a meta-analysis using the RevMan 5.3 software. A total of 20 studies were included. Analysis of these studies found that compared with interrupted use of antithrombotic agents, continuous use of antithrombotic drugs led to more frequent post-TURP bleeding (OR=4.34, 95% CI=2.29-8.23), and higher transfusion rate (2.96, 1.19-7.36). Compared with patients who never used antithrombotic agents, those who used antithrombotic agents continuously had higher bleeding risk (5.52, 1.64-18.66). Those who continued using antithrombotic agents during laser treatment had higher transfusion rate than those who stopped using them before the operation (5.39, 1.49-19.53), but it had no significant difference in clot retention, blood transfusion rate, intraoperative hemoglobin decrease and postoperative catheter-indwelling time compared with those who never used antithrombotic agents (P>0.05). Those who continued using antithrombotic agents during TURP showed less intraoperative hemoglobin decrease (-0.46, -0.58-0.35) than the patients who underwent low molecular weight heparin substitution. Interruption of antithrombotic agents during TURP can prevent the risk of postoperative bleeding; continuous use of antithrombotic agents is safe and feasible during laser treatment of BPH; whether low molecular weight heparin substitution is necessary during the discontinuation of antithrombotic agents is controversial.

Factors Associated With Extended Length of Stay and 90-Day Readmission Rates Following ACDF

STUDY DESIGN

Retrospective.

OBJECTIVE

Identify patient risk factors for extended length of stay (LOS) and 90-day hospital readmissions following elective anterior cervical discectomy and fusion (ACDF).

METHODS

Included ACDF patients from 2013 to 2017 at a single institution. Eligible patients were subset into LOS <2 and LOS ≥2 days, and no 90-day hospital readmission and yes 90-day hospital readmission. Patient and surgical factors were compared between the LOS and readmission groups. Multivariable logistic regression analysis was utilized to determine the association of independent factors with LOS and 90-day readmission rates.

RESULTS

Our sample included 1896 patients; 265 (14%) had LOS ≥2 days, and 121 (6.4%) had a readmission within 90 days of surgery. Patient and surgical factors associated with LOS included patient age ≥65 years (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.15-2.56), marriage (OR 0.57, 95% CI 0.43-0.79), private health insurance (OR 0.28, 95% CI 0.15-0.50), American Society of Anesthesiologists (ASA) score (OR 1.52, 95% CI 1.12-1.86), African American race (OR 1.95, 95% CI 1.38-2.72), and harvesting iliac crest autograft (OR 4.94, 95% CI 2.31-10.8). Patient and surgical factors associated with 90-day hospital readmission included ASA score (OR 1.81, 95% CI 1.32-2.49), length of surgery (OR 1.002, 95% CI 1.001-1.004), and radiculopathy as indication for surgery (OR 0.60, 95% CI 0.39-0.96).

CONCLUSIONS

Extended LOS and 90-day hospital readmissions may lead to poorer patient outcomes and increased episode of care costs. Our study identified patient and surgical factors associated with extended LOS and 90-day readmission rates. In general, preoperative patient factors affected these outcomes more than surgical factors.

Longer Operative Time Is Independently Associated With Surgical Site Infection and Wound Dehiscence Following Open Reduction and Internal Fixation of the Ankle

Background: Little is known regarding the association of operative time with adverse events following foot and ankle surgery. This study tests whether greater operative time is associated with the occurrence of adverse events following open reduction and internal fixation (ORIF) of the ankle. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for cases of ankle ORIF (primary CPT codes 27766, 27769, 27792, 27814, 27822, 27823) performed during 2005-2016. Operative time was tested for association with the occurrence of adverse events with controls for baseline characteristics and primary CPT code. Results: A total of 20 591 procedures met inclusion/exclusion criteria. The average (±SD) operative time was 75.7 (±37.3) minutes and varied by baseline characteristics and primary CPT code. After controlling for these factors, a 15-minute increase in operative time was associated with an 11% increase in risk for developing surgical site infection (SSI; relative risk [RR]: 1.11; 95% CI: 1.06-1.16), 20% for wound dehiscence (RR: 1.20; 95% CI: 1.11-1.29), 10% for anemia requiring transfusion (RR: 1.10; 95% CI: 1.04-1.17), 60% for cerebrovascular accident (RR: 1.60; 95% CI: 1.17-2.18), 14% for unplanned intubation (RR: 1.14; 95% CI: 1.03-1.26), and 7% for extended length of hospital admission (RR: 1.07; 95% CI: 1.05-1.09). Conclusion: Operative time is linearly and independently associated with the risks for SSI, wound dehiscence, and other adverse events following ORIF of the ankle. Efforts should be implemented to safely minimize operative duration without compromising the technical components of the procedure. Levels of Evidence: Therapeutic, Level IV.

Late deep cervical infection after anterior cervical discectomy and fusion: a case report and literature review

Background

Anterior cervical discectomy and fusion (ACDF) is often performed for the treatment of degenerative cervical spine. While this procedure is highly successful, 0.1–1.6% of early and late postoperative infection have been reported although the rate of late infection is very low.

Case presentation

Here, we report a case of 59-year-old male patient who developed deep cervical abscess 30 days after anterior cervical discectomy and titanium cage bone graft fusion (autologous bone) at C3/4 and C4/5. The patient did not have esophageal perforation. The abscess was managed through radical neck dissection approach with repated washing and removal of the titanium implant. Staphylococcus aureus was positively cultured from the abscess drainage, for which appropriate antibiotics including cefoxitin, vancomycin, levofloxacin, and cefoperazone were administered postoperatively. In addition, an external Hallo frame was used to support unstable cervical spine. The patient’s deep cervical infection was healed 3 months after debridement and antibiotic administration. His cervial spine was stablized 11 months after the surgery with support of external Hallo Frame.

Conclusions

This case suggested that deep cervical infection should be considered if a patient had history of ACDF even in the absence of esophageal perforation.

A 15-Minute Incremental Increase in Operative Duration Is Associated With an Additional Risk of Complications Within 30 Days After Arthroscopic Rotator Cuff Repair

Background:

Operative time is a risk factor for short-term complications after orthopaedic procedures; however, it has yet to be investigated as an independent risk factor for postoperative complications after arthroscopic rotator cuff repair.

Purpose:

To determine whether operative time is an independent risk factor for complications, readmissions, and extended hospital stays within 30 days after arthroscopic rotator cuff repair.

Study Design:

Descriptive epidemiology study.

Methods:

The American College of Surgeons National Surgical Quality Improvement Program was queried for all hospital-based inpatient and outpatient arthroscopic rotator cuff repairs (Current Procedural Terminology code 29827) from 2005 to 2016. Concomitant procedures such as subacromial decompression, biceps tenodesis, superior labrum anterior and posterior (SLAP) repair, labral repair, and distal clavicle excision were also included, whereas patients undergoing arthroplasty were excluded from the study. Operative time was correlated with patient demographics, comorbidities, and concomitant procedures. All adverse events were correlated with operative time, while controlling for the above preoperative variables, using multivariate Poisson regression with a robust error variance.

Results:

A total of 27,524 procedures met inclusion and exclusion criteria. The mean age of patients was 58.4 ± 10.9 years, the mean operative time was 86.9 ± 37.4 minutes, and the mean body mass index was 30.4 ± 7.0 kg/m². Concomitant biceps tenodesis, glenohumeral debridement, SLAP repair, labral repair, and distal clavicle excision significantly increased operative time (P < .001) but not the risk of adverse events (P > .05). The overall rate of adverse events was 0.88%. After adjusting for demographic and procedural characteristics, a 15-minute increase in operative duration was associated with an increased risk of anemia requiring transfusion (relative risk [RR], 1.27 [95% CI, 1.14-1.42]; P < .001), venous thromboembolism (RR, 1.17 [95% CI, 1.02-1.35]; P = .029), surgical site infection (RR, 1.13 [95% CI, 1.03-1.24]; P = .011), and extended length of hospital stay (RR, 1.07 [95% CI, 1.00-1.14]; P = .036).

Conclusion:

Although the rate of short-term complications after arthroscopic rotator cuff repair is low, incremental increases in operative time are associated with an increased risk of adverse events such as surgical site infection, pulmonary embolism, transfusion, and extended length of hospital stay. Efforts should be made to maximize surgical efficiency in the operating room through optimal coordination of the staff or increased preoperative planning.

Operative Time as an Independent and Modifiable Risk Factor for Short-Term Complications After Knee Arthroscopy

PURPOSE

To determine whether operative time is an independent risk factor for 30-day complications after arthroscopic surgical procedures on the knee.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried between 2005 and 2016 for all arthroscopic knee procedures including lateral release, loose body removal, synovectomy, chondroplasty, microfracture, and meniscectomy. Cases with concomitant procedures were excluded. Correlations between operative time and adverse events were controlled for variables such as age, sex, body mass index, patient comorbidities, and procedure using a multivariate Poisson regression with robust error variance.

RESULTS

A total of 78,864 procedures met our inclusion and exclusion criteria. The mean age of patients was 51.0 ± 14.3 years; mean operative time, 31.2 ± 18.1 minutes; and mean body mass index, 31.0 ± 7.8. Arthroscopic lateral release (coefficient, 5.8; 95% confidence interval [CI], 4.8-6.8; P < .001), removal of loose bodies (coefficient, 4.2; 95% CI, 3.2-5.3; P < .001), synovectomy (coefficient, 1.8; 95% CI, 1.2-2.3; P < .001), and microfracture (coefficient, 6.5; 95% CI, 5.8-7.2; P < .001) had significantly greater durations of surgery in comparison with meniscectomy. The overall rate of adverse events was 1.24%. After we adjusted for demographic characteristics and the procedure, a 15-minute increase in operative duration was associated with an increased risk of transfusion (relative risk [RR], 1.5; 95% CI, 1.3-1.8; P < .001), death (RR, 1.6; 95% CI, 1.2-2.1; P = .005), dehiscence (RR, 1.6; 95% CI, 1.2-2.2; P = .002), surgical-site infection (RR, 1.3; 95% CI, 1.2-1.3; P = .001), sepsis (RR, 1.3; 95% CI, 1.2-1.4; P < .001), readmission (RR, 1.1; 95% CI, 1.1-1.2; P < .001), and extended length of stay (RR, 1.4; 95% CI, 1.3-1.4; P < .001).

CONCLUSIONS

Marginal increases in operative time are associated with an increased risk of adverse events such as surgical-site infection, sepsis, extended length of stay, and readmission. Efforts should be made to maximize surgical efficiency.

LEVEL OF EVIDENCE

Level IV, retrospective database study.

Incidence, Risk Factors, and Clinical Implications of Postoperative Hematoma Requiring Reoperation Following Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Retrospective study of prospectively collected data.

OBJECTIVE

To determine the incidence, timing, risk factors, and clinical implications of postoperative hematoma requiring reoperation after anterior cervical discectomy and fusion (ACDF).

SUMMARY OF BACKGROUND DATA

Postoperative hematomas requiring reoperation are rare but potentially catastrophic complications after ACDF. However, there has been a lack of large cohort studies investigating these complications in the ACDF population despite increasing outpatient procedure volume.

METHODS

Patients who underwent ACDF in the 2012 to 2016 National Surgical Quality Improvement Program database were identified. The primary outcome was an occurrence of hematoma requiring reoperation within 30 days postoperatively. Risk factors for this outcome were identified using multivariate regression. Postoperative length of stay, subsequent complications, and mortality were compared between patients who did and did not develop a hematoma requiring reoperation.

RESULTS

A total of 37,261 ACDF patients were identified, of which 148 (0.40%) developed a hematoma requiring reoperation (95% confidence interval [CI], 0.33%-0.46%). Of the cases that developed this complication, 37% occurred after discharge. Risk factors for the development of hematoma requiring reoperation were multilevel procedures (most notably ≥3 levels, relative risk [RR] = 3.14, 95% CI = 1.86-5.32, P < 0.001), preoperative international normalized ratio >1.2 (RR = 2.85, 95% CI = 1.42-5.71, P = 0.006), lower BMI (notably body mass index ≤24, RR = 2.11, 95% CI = 1.21-3.67, P = 0.008), American Society of Anesthesiologists classification ≥3 (RR = 2.07, 95% CI = 1.47-2.91, P < 0.001), preoperative anemia (RR = 1.71, 95% CI = 1.12-2.63, P = 0.027), and male sex (RR = 1.67, 95% CI = 1.18-2.37, P = 0.004). In addition, patients who developed a hematoma requiring reoperation before discharge had a longer length of stay. Further, those who developed a hematoma requiring reoperation were at higher risk for subsequent ventilator requirement, deep wound infection, pneumonia, and reintubation.

CONCLUSION

Postoperative hematoma requiring reoperation occurred in approximately 1 in 250 patients after ACDF. High-risk patients should be closely monitored through the perioperative period.

LEVEL OF EVIDENCE

3.

Effect of Operative Time on Short-Term Adverse Events After Isolated Anterior Cruciate Ligament Reconstruction

Background:

A longer operative time has been previously recognized as a risk factor for short-term complications after various orthopaedic procedures; however, it has yet to be investigated as an independent risk factor for postoperative complications after anterior cruciate ligament (ACL) reconstruction.

Purpose:

To identify whether a longer operative time in ACL reconstruction is an independent risk factor for the development of postoperative complications, hospital readmissions, or an extended length of stay within 30 days of the index procedure.

Study Design:

Descriptive epidemiology study.

Methods:

Patients undergoing ACL reconstruction between 2005 and 2016 were identified using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Cases with concomitant procedures were excluded from the analysis. We evaluated the association between operative time and preoperative variables such as patient age, sex, body mass index, comorbidities, and procedure. Correlations between adverse events and operative time, while controlling for the above preoperative variables, were calculated using multivariate Poisson regression with robust error variance.

Results:

A total of 14,159 procedures were included in this investigation. The mean patient age was 32.6 ± 10.8 years, the mean body mass index was 27.7 ± 6.5 kg/m², and the mean operative time was 89.7 ± 28.6 minutes. Patients who were between the ages of 18 and 30 years (mean operative time, 95.1 ± 27.8 minutes; relative risk [RR], 17.7; P < .001), male (mean operative time, 91.9 ± 28.3 minutes; RR, 4.7; P < .001), and nondiabetic (mean operative time, 89.8 ± 28.6 minutes; RR, 7.1; P = .011) were associated with a longer operative duration. The overall complication rate was 1.1%. After adjusting for demographic characteristics and procedures, 15-minute incremental increases in operative duration were associated with an increased risk of deep vein thrombosis (RR, 1.12; P = .042), surgical site infections (RR, 1.21; P = .001), and sepsis (RR, 1.66; P < .001) as well as increased readmission rates (RR, 1.23; P = .001) and an extended length of stay (RR, 1.18; P = .008).

Conclusion:

While the overall adverse risk rate after ACL reconstruction remains low, marginal increases in operative time are associated with an increased risk of adverse events such as deep vein thrombosis, surgical site infections, sepsis, an extended length of stay, and readmissions. Thus, the operating physician and surgical staff should make all efforts to coordinate and prepare for each case to maximize surgical efficiency.

Is Discharge Within a Day of Total Knee Arthroplasty Safe in the Octogenarian Population?

BACKGROUND

Reduced hospital stay programs for total knee arthroplasty (TKA) are being implemented in order to increase patient satisfaction and reduce healthcare costs. Although elderly patients are often included in these pathways, there have been limited data on whether older patients can safely be discharged within a day after TKA. The purpose of this study is to compare perioperative complications following primary TKA with ≤1 day in the hospital in patients aged ≥80 compared to <80 years old in the National Surgical Quality Improvement Program database.

METHODS

Patients who underwent primary TKA with hospital length of stay ≤1 day were identified in the 2005-2016 National Surgical Quality Improvement Program database. These patients were separated into 2 age groups: <80 and ≥80 years old. Preoperative and procedural characteristics were compared. Multivariate regressions were used to compare risk for perioperative adverse events and readmission. Independent risk factors for serious adverse events following such TKAs were identified.

RESULTS

In total, 17,191 (<80 year olds) and 1005 (≥80 year olds) cases were identified. Of these patients, 1750 cases were discharged the same day. Multivariate analysis revealed only higher risk for 30-day readmission and nonhome discharge in ≥80 compared to <80 year olds. Notably, the octogenarians had a significantly higher rate of nonsurgical site-related readmissions. Independent risk factors for serious adverse events include only American Society of Anesthesiologists score ≥3 and not patient age.

CONCLUSION

These data suggest that, although octogenarians can safely be discharged in ≤1 day, greater postdischarge care may be warranted to reduce the rate of nonsurgical site-related readmissions.