Surgeon Case Research Articles

Hospital and surgeon experience and patient health outcomes after coronary artery bypass graft surgery

AbstractThe Hospital Readmissions Reduction Program imposes financial penalties on hospitals with excess readmission rates for various conditions, including coronary artery bypass graft (CABG) surgery. While prior research has focused mainly on hospital‐specific factors and their impact on patient mortality, surgeon risk factors and patient outcomes, such as readmission risk, have received less attention. We study three drivers of CABG readmission risk—hospital and surgeon case volume, variation in surgeon volume, and surgeon familiarity with hospitals. Drawing on unique patient data sets of CABG surgeries spanning 3 years, we study the relationships between hospital and surgeon case volume, readmission risk, and postoperative length of stay (PLOS). We find evidence of an inverted U‐shaped relationship between case volume and readmission risk and a U‐shaped relationship with PLOS. Our results also indicate that surgeon volume variation moderates the relationship between surgeon volume and readmission risk, where readmission risk increases with greater variation in surgeon volume. We observe that the impact of surgeon experience on readmission risk at the focal hospital outweighs their experience at other hospitals. Our study has significant implications for hospital resource management as it highlights the role of surgeon and hospital experience in improving patient outcomes after CABG surgery.

How Long Does It Take to Acquire Mastery of Performance in Laparoscopic Living Donor Nephrectomy? A Center-Based and Surgeon-Based Operative Time CUSUM Analysis

The safety of laparoscopic donor nephrectomy (LDN) has been widely documented, but its challenging learning curve (LC) requires an insightful assessment to expand its application. The aim of this study was to evaluate LC of LDN in a high-volume transplant center. Three hundred forty-three LDNs performed from 2001 to 2018 were evaluated. CUSUM analysis based on the operative time was used to assess the number of cases required to reach mastery in the technique for both the entire surgical team and for the 3 main surgeons considered separately. Analysis of association between demographics, perioperative characteristics, and complications within the different LC phases was conducted. Mean operative time was 228.9 minutes. Mean length of stay was 3.8 days and mean warm ischemia time (WIT) was 170.8 seconds. Surgical and medical complication rates were 7.3% and 6.4%, respectively. The CUSUM-LC showed a requirement of 157 cases (for surgical team) and 75 cases (for single surgeons) to reach competence in the procedure. Patient baseline characteristic showed no differences among the LC phases. Compared with the initial LC phase, hospital stay was significantly lower at the end of the LC whereas WIT results were longer in the LC descendent phase. This study confirms the safety and efficacy of LDN, with a low rate of complications. This analysis suggests that about 75 procedures are required to reach competence and 93 cases to achieve mastery level of skill for a single surgeon. It can be hypothesized that, in a high-volume transplant enter, the time to guarantee training in LDN is compatible with the duration of a clinical fellowship.

No short-term clinical improvement and mean 6° of thoracic kyphosis correction using limited-level Ponte osteotomy near T7 for Lenke type 1 and 2 adolescent idiopathic scoliosis: a preliminary study.

This study was a retrospective single surgeon case series approved by institutional review board and showed the efficacy of limited Ponte osteotomy at T6/7, 7/8 and 8/9 (limited-PO) in the sagittal plane for patients with Lenke type 1 and 2 adolescent idiopathic scoliosis (AIS). A total of 37 consecutive patients [7 males and 30 females; average age 16.0 ± 2.5 (range: 12-21)] over a 4-year period with posterior corrective fusion surgery were included. Initially, 18 patients were operated on without limited-PO [P(-)-group]. Midway in the series, the senior author switched to the limited-PO [P(+)-group]. The limited-PO has been performed to form the apex of thoracic kyphosis at the T7 level, together with the restoration of thoracic kyphosis. The mean amount of the correction angle of thoracic kyphosis was more in the P(+)-than in P(-)-group (13.8 ± 9.6° vs. 7.8 ± 8.0°, P = 0.046) at 1-year after surgery. Cervical lordosis was spontaneously corrected more in P(+)-than in P(-)-group. The apex of thoracic kyphosis was controlled around the T7 level postoperatively in most cases (18/19 cases). There was no significant difference between the two groups in terms of blood loss and operative time per level, or Scoliosis Research Society-22 domain scores. Limited-PO contributed to the restoration of the whole spinal sagittal alignment for Lenke type 1 and 2 AIS; however, in this preliminary study, the clinical improvement was unclear at least in the short term, because the kyphosis angle obtained by limited-PO was only approximately 6°.

Evaluation of the learning curve for laparoscopic pyloromyotomy.

Laparoscopic pyloromyotomy is the preferred surgical management of hypertrophic pyloric stenosis at most centers. We aimed to analyze the learning curve for laparoscopic pyloromyotomy using the experience of five fellowship-trained pediatric surgeons. A retrospective review of consecutive patients undergoing laparoscopic pyloromyotomy was performed. All cases were performed with general surgery residents. Cumulative sum (CUSUM) analysis for operating time was performed for up to the first 150 consecutive cases for individual surgeons. Outcomes were compared to identify different phases of the learning curve for operative competency. A total of 414 patients were included in the analysis as not all surgeons had reached 150 cases at time of analysis. The mean operating time was 29.2min for all cases across the 5 surgeons. CUSUM analysis for mean operating time revealed three phases of learning: Learning Phase (cases 1-16), Plateau Phase (cases 17-87), and a Proficiency Phase (cases 88-150). The mean operating time during the three phases was 34.1, 29.0, and 28.3min, respectively (P = 0.005). There were no differences in complications, reoperations, length of stay, or readmissions across the three phases. Three distinct phases of learning for laparoscopic pyloromyotomy were identified with no differences in outcomes across the phases. The operating time differed only for the Learning Phase, suggesting that some degree of proficiency occurs after 16 cases.

Urinary incontinence after endoscopic enucleation of the prostate with the Holmium laser: Evolutionary aspects and associated predictive factors

To study the evolutionary aspects of stress urinary incontinence and urinary incontinence by urgency after HoLEP through a series of 200consecutive cases of the same surgeon then to seek secondarily the predictive factors of occurrence in the service of urology of the Hospital Center of Martigues. This was a monocentric, retrospective, descriptive and analytical study conducted in the urology department of the Martigues Hospital. All patients who were treated with HoLEP for benign prostatic hypertrophy (BPH) between September 2017and March 2021were included in the study. Patients with an age greater than 75years, obese (BMI>30) or with neurological disease were excluded from this study. Between September 2017and March 2021, 204patients were included in our study. The average urinary incontinence rate was 21.2% 12.2% 7.4% and 2.7% at 1month, 3months, 6months and 12months respectively. The rate of stress urinary incontinence was 5.4%, 9.2%, 5.6% and 1.8% at 1month, 3months, 6months and 12months post HoLEP respectively. Urge urinary incontinence was estimated at 13.3%, 3%, 1.8% and 0.9% at M1, M3, M6and M12post-HoLEP respectively. Preoperative erectile dysfunction, delivered energy, enucleated prostate weight and total intraoperative time were statistically associated with the occurrence of stress urinary incontinence postoperatively. The operative time and a low operative Qmax were statistically associated with the occurrence of postoperative stress urinary incontinence. HoLEP is at risk of postoperative urinary incontinence. Preoperative information of the patients on the risk of urinary incontinence is essential.

Robotik retropubik prostatektomiye aşina cerrahlar için robot yardımlı perineal prostatektomi için öğrenme eğrisi

Objective: To investigate the learning curve for robot assisted laparoscopic radical perineal prostatectomy (robotic RPP) for surgeons who already perform transperitoneal robot assisted laparoscopic radical prostatectomy. Material and Methods: A total of initial 120 robotic RPP cases were analyzed for perioperative data from single surgeon performing to determine the learning curve. Perioperative all data are collected including operation time, estimated blood loss, postoperative length of stay, complications and positive surgical margin results. The consecutive patients were classified into four groups: cases 1–30 (Group 1), cases 31–60 (Group 2), cases 61–90 (Group 3) and cases 91-120 (Group 4). Results: Median age of 61.4 (46-73) years and PSA level was 8.4 (2-32). Mean operative time was 143.2 minutes, and the length of surgery progressively decreased over time (from group 1 to group 4; P<001). Mean console time was 90.6 minutes and significant differences was found group 3 vs. 4 (p=0.047). The mean length of stay was 1.6 days, and significantly decrease after 60 cases over time (P<0.001). Mean removal of the urethral catheter significantly earlier in group 4 (P1vs4=0.012). There was no statistically significant difference between the groups with respect to pathologic tumor Gleason score, positive surgical margine of the specimen and complications. Conclusions: This study suggests that surgical qualification for robotic RPP can be obtained at least after 90 cases for an experienced robotic surgeon. Keywords: prostatectomy, robot-assisted, perineal, learning curve, prostate cancer

Determinants of Operative Time in Arthroscopic Rotator Cuff Repair

Arthroscopic rotator cuff repairs have been reported to take between 72 and 113 min to complete. This team has adopted its practice to reduce rotator cuff repair times. We aimed to determine (1) what factors reduced operative time, and (2) whether arthroscopic rotator cuff repairs could be performed in under 5 min. Consecutive rotator cuff repairs were filmed with the intent of capturing a <5-min repair. A retrospective analysis of prospectively collected data of 2232 patients who underwent primary arthroscopic rotator cuff repair by a single surgeon was performed using Spearman's correlations and multiple linear regression. Cohen's f2 values were calculated to quantify effect size. Video footage of a 4-min arthroscopic repair was captured on the 4th case. Backwards stepwise multivariate linear regression found that an undersurface repair technique (f2 = 0.08, p < 0.001), fewer surgical anchors (f2 = 0.06, p < 0.001), more recent case number (f2 = 0.01, p < 0.001), smaller tear size (f2 = 0.01, p < 0.001), increased assistant case number (f2 = 0.01, p < 0.001), female sex (f2 = 0.004, p < 0.001), higher repair quality ranking (f2 = 0.006, p < 0.001) and private hospital (f2 = 0.005, p < 0.001) were independently associated with a faster operative time. Use of the undersurface repair technique, reduced anchor number, smaller tear size, increased surgeon and assistant surgeon case number, performing repairs in a private hospital and female sex independently lowered operative time. A <5-min repair was captured.

Surgical Simulation of Posterior Sagittal Anorectoplasty for Rectovestibular Fistula: Low-Cost High-Fidelity Animal-Tissue Model

PurposeTo provide a high-fidelity, animal tissue-based model for the advanced surgical simulation of a Posterior Sagittal Anorectoplasty (PSARP) for rectovestibular fistula in anorectal malformation (ARM). Materials and methodsA chicken cadaver was used to assess the feasibility of simulating a PSARP for rectovestibular fistula in ARM. No modification was required to implement the surgical simulation. ResultsA detailed description of the high-fidelity surgical simulation model is provided. The PSARP can be simulated while providing realistic anatomy (e.g. common wall between rectovestibular fistula and vagina), adequate rectal size, location and placement of the rectovestibular fistula, and proximity to the vagina. Haptic conditions of the tissue resemble human tissue and operative conditions as well. DiscussionConcerning the decreased exposure of index cases of pediatric surgical trainees and pediatric surgeons in practice, simulation-based training can provide means to acquire or maintain the necessary skills to perform complex surgical procedures [1–5]Surgical simulation models for ARM are limited. Few low-cost trainers are available with predominant artificial and mostly unrealistic tissue [6–8] Animal models have the advantage of realistic multilayer tissue haptic feedback [6]. ConclusionWe provide a low-cost, high-fidelity model for correcting a rectovestibular fistula in a child with ARM, a complex operative procedure with low incidence but high-stake outcomes. The described tissue model utilizing the chicken cloaca anatomy provides a high-fidelity model for operative correction of rectovestibular ARM. For simulation purposes in the treatment of ARM, this model appears to be promising in terms of providing realistic pathology and haptic feedback in pediatric dimensions. Level of evidenceV.

Influence of the learning curve on the immediate postoperative pain intensity after laparoscopic inguinal hernioplasty.

Inguinal hernia repairs represent one of the most commonly performed surgical operations worldwide. As more experience has been gained over the past decades with laparoscopic techniques, they are now widely used also for the repair of primary and unilateral inguinal hernias, representing a safe and effective alternative. One of the major concerns of patients undergoing inguinal hernia repair is postoperative pain and socio-professional reintegration. This study started from the hypothesis that the learning curve could influence postoperative pain intensity after laparoscopic inguinal hernioplasty. A retrospective - comparative study was performed, including a general surgeon's first consecutive cases (n=87) of TAPP (transabdominal preperitoneal procedure) hernioplasty procedures with implantation of self-gripping surgical prosthesis were investigated. The evaluation of clinical and surgical aspects resulted in similar values in case of the studied groups. A reduction in surgical time was observed in case of patients operated after completing the learning curve (p = 0.0005) On the first postoperative day patients complained mostly about persistent and severe type of pain. Average Pain Index calculated with help of Simple Numeric Pain Scale resulted in similar values. Length of analgesic treatment showed no significant differences. Although higher intensity pain was mostly caracteristic in case of patients operated during the learning process, no significant relationship between learning curve and postoperative pain intensity were highlited. TAPP can be a safe technique for young surgeons as well, with the right study program the procedure can be mastered safely.

Effective peer review audit and identification of the surgeon outlier.

Surgical audit aims to identify ways to maintain and improve the quality of care for patients, in part by assessment of a surgeon's activities and outcomes. However effective data systems to facilitate audit are uncommon. We aimed to assess the effectiveness of a tool for Peer Review Audit. All General Surgeons in Darwin and the Top End were encouraged to self-record their surgical activity, including procedures and adverse events related to procedures, using the College's Morbidity Audit and Logbook Tool (MALT). A total of 6 surgeons and 3518 operative events were recorded in MALT between 2018 and 2019. De-identified reports of each surgeon's activities, compared directly to the audit group, were created by each surgeon, with correction for complexity of procedures and ASA status. Nine complications Grade 3 and greater were recorded, plus 6 deaths, 25 unplanned returns to theatre (8% failure to rescue rate), 7 unplanned admissions to ICU and 8 unplanned readmissions. One surgeon outlier was identified (>3 standard deviation over group mean) for unplanned returns to theatre. This surgeon's specific cases were reviewed at our morbidity and mortality meeting using the MALT Self Audit Report and changes were implemented as a result, with future progress monitored. The College's MALT system effectively enabled Peer Group Audit. All participating surgeons were readily able to present and validate their own results. A surgeon outlier was reliably identified. This led to effective practice change. The proportion of surgeons who participated was low. Adverse events were likely under-reported.

Effect of Surgical Care Team Consistency During Urologic Procedures on Surgical Efficiency and Perioperative Outcomes

To evaluate the effect of urologic surgical care team consistency on surgical efficiency and patient outcomes. Patients undergoing major urologic surgery (prostatectomy, nephrectomy, or cystectomy) at a single institution from 2010 through 2019 were identified. A surgical care team comprised a certified surgical assistant, certified surgical technologist, and circulating nurse. Primary team member status was assigned on a quarterly basis to team members present for the highest proportion of a surgeon's cases. Surgical efficiency outcomes included time to first incision, procedure duration, and turnover time. Perioperative clinical outcomes included hospital length of stay and 30-day readmission and reoperation rates. Outcomes were compared according to team consistency and assessed via univariate and multivariable analyses. Overall, 11,213 surgical procedures were included. Time to first incision, procedure duration, and turnover time were significantly lower in procedures performed with high-consistency teams (2-3 primary members) vs low-consistency teams (0-1 primary members) (all P<.001). After adjusting for patient-related variables, high-consistency teams were significantly associated with decreased time to first incision (estimate, -2.04 minutes; 95% CI, -2.68 to -1.41 minutes; P<.001) and turnover time (estimate, -7.23 minutes; 95% CI, -9.8 to -4.66 minutes; P<.001). For minimally invasive nephrectomy, high-consistency teams were associated with significantly decreased odds of prolonged hospitalization (odds ratio, 0.63; 95% CI, 0.47-0.84; P=.001). For robotic prostatectomy, high-consistency teams were associated with decreased procedure duration (estimate, -4.55 minutes; 95% CI, -7.48 to -1.62 minutes; P=.002). Highly consistent surgical care teams were associated with improved surgical efficiency and patient outcomes.

Effect of annualized surgeon volume on major surgical complications for abdominal and laparoscopic radical hysterectomy for cervical cancer in China, 2004–2016: a retrospective cohort study

BackgroundPrevious studies have suggested that higher surgeon volume leads to improved perioperative outcomes for oncologic surgery; however, the effect of surgeon volumes on surgical outcomes might differ according to the surgical approach used. This paper attempts to evaluate the effect of surgeon volume on complications or cervical cancer in an abdominal radical hysterectomy (ARH) cohort and laparoscopic radical hysterectomy (LRH) cohort.MethodsWe conducted a population-based retrospective study using the Major Surgical Complications of Cervical Cancer in China (MSCCCC) database to analyse patients who underwent radical hysterectomy (RH) from 2004 to 2016 at 42 hospitals. We estimated the annualized surgeon volumes in the ARH cohort and in the LRH cohort separately. The effect of the surgeon volume of ARH or LRH on surgical complications was examined using multivariable logistic regression models.ResultsIn total, 22,684 patients who underwent RH for cervical cancer were identified. In the abdominal surgery cohort, the mean surgeon case volume increased from 2004 to 2013 (3.5 to 8.7 cases) and then decreased from 2013 to 2016 (8.7 to 4.9 cases). The mean surgeon case volume number of surgeons performing LRH increased from 1 to 12.1 cases between 2004 and 2016 (P < 0.01). In the abdominal surgery cohort, patients treated by intermediate-volume surgeons were more likely to experience postoperative complications (OR = 1.55, 95% CI = 1.11–2.15) than those treated by high-volume surgeons. In the laparoscopic surgery cohort, surgeon volume did not appear to influence the incidence of intraoperative or postoperative complications (P = 0.46; P = 0.13).ConclusionsThe performance of ARH by intermediate-volume surgeons is associated with an increased risk of postoperative complications. However, surgeon volume may have no effect on intraoperative or postoperative complications after LRH.

The implications of surgeon case volume and hospital volume on outcomes of aortobifemoral bypasses in obese patients

BackgroundAortobifemoral (ABF) bypass is the gold standard for treating symptomatic aortoiliac occlusive disease. In the era of heightened interest in the length of stay (LOS) for surgical patients, this study aims to investigate the association of obesity with postoperative outcomes at the patient, hospital, and at surgeon levels. MethodsThis study used the Society of Vascular Surgery Vascular Quality Initiative suprainguinal bypass database from 2003 to 2021. The selected study cohort was divided into obese patients (body mass index ≥30) (group I) and nonobese patients (body mass index <30) (group II). Primary outcomes of the study included mortality, operative time, and postoperative LOS. Univariate and multivariate logistic regression analyses were performed to study the outcomes of ABF bypass in group I. Operative time and postoperative LOS were transformed into binary values by median split for regression analysis. A P value of .05 or less was deemed statistically significant in all the analyses of this study. ResultsThe study cohort consisted of 5392 patients. In this population, 1093 were obese (group I) and 4299 were nonobese (group II). Group I was found to have more females with higher rates of comorbid conditions, including hypertension, diabetes mellitus, and congestive heart failure. Patients in group I had increased odds of prolonged operative time (≥250 minutes) and an increased LOS (≥6 days). Patients in this group also had a higher chance of intraoperative blood loss, prolonged intubation, and required vasopressors postoperatively. There was also an increased odds of postoperative decline in renal function in the obese population. Patients with prior history of coronary artery disease, hypertension, diabetes mellitus, and urgent or emergent procedures were found to be risk factors for a LOS of more than 6 days in obese patients. An increase in the surgeons' case volume was associated with lesser odds of an operative time of 250 minutes or more; however, no significant impact was found on postoperative LOS. Hospitals where 25% or more of ABF bypasses were performed on obese patients were also more likely to have LOS of less than 6 days after ABF operations, compared with hospitals where less than 25% of ABF bypasses were performed on obese patients. Patients undergoing ABF for chronic limb-threatening ischemia or acute limb ischemia had a longer LOS and increased operative times. ConclusionsABF bypass in obese patients is associated with prolonged operative times and a longer LOS than in nonobese patients. Obese patients operated by surgeons with more cases of ABF bypasses have shorter operative times. A hospital's increasing proportion of obese patients was related to a decreased LOS. These findings support the known volume-outcome relationship that, with a higher surgeon case volume and increased proportion of obese patients in a hospital, there is an improvement in outcomes of obese patients undergoing ABF bypass.

HIGHER RISK OF MEDIAL MENISCAL REPAIR FAILURE FOLLOWING CONCURRENT ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION WITH A HAMSTRING TENDON AUTOGRAFT

Meniscal repairs are commonly performed during anterior cruciate ligament (ACL) reconstruction. This study aimed to identify the risk factors for meniscal repair failure following concurrent primary ACL reconstruction.Primary ACL reconstructions with a concurrent repair of a meniscal tear recorded in the New Zealand ACL Registry between April 2014 and December 2018 were analyzed. Meniscal repair failure was defined as a patient who underwent subsequent meniscectomy, and was identified after cross-referencing data from the ACL Registry with the national database of the Accident Compensation Corporation (ACC). Multivariate Cox regression was performed to produce hazard ratios (HR) with 95% confidence intervals (CI) to identify the patient and surgical risk factors for meniscal repair failure.2041 meniscal repairs were analyzed (medial = 1235 and lateral = 806). The overall failure rate was 9.4% (n = 192). Failure occurred in 11.1% of medial (137/1235) and 6.8% of lateral (55/806) meniscal repairs. The risk of medial failure was higher with hamstring tendon autografts (adjusted HR = 2.00, 95% CI 1.23 – 3.26, p = 0.006) and in patients with cartilage injury in the medial compartment (adjusted HR = 1.56, 95% CI 1.09 – 2.23, p = 0.015). The risk of lateral failure was higher when the procedure was performed by a surgeon with an annual case volume of less than 30 ACL reconstructions (adjusted HR = 1.92, 95% CI 1.10 – 3.33, p = 0.021). Age, gender, time from injury-to-surgery and femoral tunnel drilling technique did not influence the risk of meniscal repair failure.When repairing a meniscal tear during ACL reconstruction, the use of a hamstring tendon autograft or the presence of cartilage injury in the medial compartment increases the risk of medial meniscal repair failure. Lower surgeon case volume increases the risk of lateral meniscal repair failure.

Does Direct Anterior Approach Training During Residency and Fellowship Influence Clinical and Surgical Outcomes in Primary Total Hip Arthroplasty?

Background and Hypothesis: Total hip arthroplasty (THA) can be performed using various surgical approaches. The direct anterior approach (DAA) has been popularized due to fewer immediate postoperative functional restrictions. However, when transitioning from a posterior based approach, the DAA has a steep learning curve associated with higher early complication rates. The influence of formal residency and fellowship training on the DAA learning curve remains unknown. We hypothesized that formal training would reduce the learning curve associated with DAA THA resulting in better outcomes than previously reported.&#x0D; Project Methods: Prospectively documented data on 726 unilateral primary THAs were retrospectively reviewed. Intraoperative, perioperative, and 90-day postoperative outcomes were compared for the index surgeon with formal DAA training and four surgeons without formal DAA training. A Bonferroni-adjusted p-value of 0.004 denoted statistical significance. Fourteen additional covariates were examined in relationship to outcomes.&#x0D; Results: Intraoperative fracture and nerve damage, calculated blood loss and blood transfusions, and 90-day emergency department visits, inpatient readmissions, reoperations, and wound complications did not differ between the two groups (p = .054 to .999). Mean procedure (140 versus 103) and anesthesia (192 versus 144) durations in minutes were significantly longer for index surgeon cases (p &lt; .001). In multivariable analysis, statistically significant covariates of procedure and anesthesia durations were unreliable due to wide 95% confidence intervals.&#x0D; Potential Impact: Excluding procedure and anesthesia durations, there were no significant differences in outcomes comparing a surgeon with formal DAA training to surgeons without formal training. Surgery durations may have been influenced by a difference in years of practice (first two years for the index surgeon and a mean of 16.5 years for comparison surgeons). Formal surgical training on the DAA may facilitate similar outcomes earlier in a surgeon’s practice, reducing the learning curve associated with the DAA.

Five-Year Follow-up of Third-Generation Percutaneous Chevron and Akin Osteotomies (PECA) for Hallux Valgus.

Recent large studies of third-generation minimally invasive hallux valgus surgery (MIS) have demonstrated significant improvement in clinical and radiologic outcomes. It remains unknown whether these clinical and radiologic outcomes are maintained in the medium to long term. The aim of this study was to investigate the minimum 5-year clinical and radiologic outcomes following third-generation MIS hallux valgus surgery in the hands of a high-volume MIS surgeon. A retrospective observational single highly experienced MIS surgeon case series of consecutive patients undergoing primary isolated third-generation percutaneous chevron and Akin osteotomies (PECA) for hallux valgus with a minimum 60-month clinical and radiographic follow-up. Primary outcome was radiographic assessment of the hallux valgus angle (HVA) and intermetatarsal angle (IMA) preoperatively, 6 months, and ≥60 months following PECA. Secondary outcomes included the Manchester-Oxford Foot Questionnaire, patient satisfaction, EuroQol-5D visual analog scale and the visual analog scale for pain. Between 2012 and 2014, 126 consecutive feet underwent isolated third-generation PECA, with complete data available for 78 (61.9%) feet. The median follow-up was 65.0 (IQR 64-69; range 60-88) months. There was a significant improvement in radiographic deformity correction; the median IMA improved from 12.0 degrees (interquartile range [IQR]: 10.8-14.2) to 6.0 degrees (IQR: 4.2-7.3) (P < .001), and the median HVA improved from 27.2 degrees (IQR: 20.6-34.4) to 7.2 degrees (IQR: 3.4-11.6). Median MOXFQ Index score at ≥60-month follow-up was 2.3 (IQR: 0.0-7.8). The radiographic recurrence rate (defined as HVA >15 degrees) was 7.7% at final follow-up. The complication rate was 4.8%. Radiologic deformity correction for the 78 feet we were able to follow that had third-generation PECA performed by a single highly experienced MIS surgeon was found to be maintained at a mean follow-up of average 66.8 months, with a radiographic recurrence rate of 7.7%. Clinical PROMs and patient satisfaction levels were high and comparable to other third-generation studies with shorter duration of follow-up. Level IV, retrospective cohort study.

Report of the 2022 Society of Thoracic Surgeons Congenital Heart Surgery Practice Survey

BackgroundThe Society of Thoracic Surgeons Workforce on Congenital Surgery performed a practice survey to analyze contemporary data. MethodsAn electronic survey was sent to congenital heart surgeons in North America. Details on demographics, training paradigm, clinical practice, and work satisfaction were queried, tabulated, and analyzed. ResultsOf 312 unique contacts, 201 (64.4%) responded. Of these, 178 (89%) were practicing. The median age was 52 years (interquartile range, 43, 59 years), and 157 (88%) were male. The number of female respondents increased from 12 (7%) in 2015 to 18 (11%) at present. Practice composition was predominantly mixed pediatric and adult (141; 79%), although 15 (8%) surgeons practiced exclusively pediatric surgery. Most surgeons (154; 87%) reported performing the Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category 4 and 5 procedures. One-fourth (42; 24%) reported performing fewer than 50 pediatric cases per year, and 18 (10%) stated that their primary role was as a surgical assistant. Individual surgeon case volume was most commonly 100 to 149 total cases (29%). Although one-half (91; 51%) reported their volume as being “just right,” 74 (42%) reported that their case volume was “too small.” Seventy-six (43%) reported too many surgeons in their region. Of the 201 practicing surgeons, 30 (14.9%) plan retirement in the next 5 years. Most described career satisfaction, with 102 (57%) being very satisfied and 48 (27%) somewhat satisfied. ConclusionsAlthough most congenital heart surgeons in North America are satisfied with their careers, more than 40% believe that their caseload is inadequate and that there are too many surgeons in their region. Further analysis is warranted regarding career dissatisfaction and diversity.

Leveraging large, real-world data through machine-learning to increase efficiency in robotic-assisted total knee arthroplasty.

Increased operative time can be due to patient, surgeon and surgical factors, and may be predicted by machine learning (ML) modeling to potentially improve staff utilization and operating room efficiency. The purposes of our study were to: (1) determine how demographic, surgeon, and surgical factors affected operative times, and (2) train a ML model to estimate operative time for robotic-assisted primary total knee arthroplasty (TKA). A retrospective study from 2007 to 2020 was conducted including 300,000 unilateral primary TKA cases. Demographic and surgical variables were evaluated using Wilcoxon/Kruskal-Wallis tests to determine significant factors of operative time as predictors in the ML models. For the ML analysis of robotic-assisted TKAs (> 18,000), two algorithms were used to learn the relationship between selected predictors and operative time. Predictive model performance was subsequently assessed on a test data set comparing predicted and actual operative time. Root mean square error (RMSE), R2 and percentage of predictions with an error < 5/10/15min were computed. Males, BMI > 40kg/m2 and cemented implants were associated with increased operative time, while age > 65yo, cementless, and high surgeon case volume had reduced operative time. Robotic-assisted TKA increased operative time for low-volume surgeons and decreased operative time for high-volume surgeons. Both ML models provided more accurate operative time predictions than standard time estimates based on surgeon historical averages. This study demonstrated that greater surgeon case volume, cementless fixation, manual TKA, female, older and non-obese patients reduced operative time. ML prediction of operative time can be more accurate than historical averages, which may lead to optimized operating room utilization. III.

Factors Affecting the Complication Rate of Septoplasty: Analysis of 1,506 Consecutive Cases of Single Surgeon.

Based on the analysis of a single surgeon's consecutive cases, we present the incidence of septoplasty complications and factors that contribute to the increased risk of complications. We retrospectively reviewed the medical records from 1,506 patients diagnosed with deviated nasal septum who underwent septoplasty by a single surgeon from January 2003 until May 2020. The incidence of different complications was investigated. Predisposing factors for specific complications were examined with univariate analysis. The average age of patients was 35 (11-76) years. Out of 1,506 patients, 1,252 were male, and 254 were female. The most frequent complication was insufficient correction (78 cases, 5.2%), and revision septoplasty was performed in 21 cases. We also reported 59 (3.9%), 55 (3.7%), 33 (2.2%), 20 (1.3%), and 18 (1.2%) cases of olfactory dysfunction, hematoma, synechia, abscess, and septal mucosal defect, respectively. Additionally, there were nine (0.6%), six (0.4%), five (0.3%), four (0.3%), and four (0.3%) cases of septal perforation, postoperative bleeding, saddle nose, chondritis, empty nose syndrome, respectively. The proportion of insufficient correction was higher in revision cases than in primary cases. Hematoma formation, abscess formation, and septal mucosal defect occurred more frequently in the bilateral flap elevation group. Olfactory dysfunction was significantly more frequent when the bony batten was inserted, while hematoma, abscess formation, and septal mucosal defect were more frequent when the cartilage batten was used. Septoplasty was associated with the risk of several complications, while complication rates were influenced by choice of surgical techniques and approaches.

Treatment strategies for cervical spondylotic myelopathy-is laminectomy alone a safe and effective option?

Cervical laminectomy may be underutilized in the treatment of cervical spondylotic myelopathy (CSM) due to concerns regarding potential for post-operative instability and/or kyphosis. The purpose of this retrospective, observational study is to assess the short-term clinical and radiological outcomes as well as complications associated with a group of carefully selected patients who underwent laminectomy alone for CSM and compared them to a cohort of patients who underwent laminectomy with fusion. Patients with CSM were identified via review of a single surgeon's cases. All patients underwent preoperative clinical evaluation, lateral flexion-extension cervical radiographs, and documentation of neck and/or extremity pain via Nurick Scale and modified Japanese Orthopedic Association (JOA) scores. Postoperative follow-up occurred at 1, 3 and 6 months for all patients. Statistical analysis was performed via Student's t-test for parametric values and Wilcoxon (Mann-Whitney) rank sum test for ordinal scores. Multi-variable linear regression was used to correct for co-variance. Forty-one patients who underwent laminectomy alone and 13 patients who underwent laminectomy with fusion were identified who met inclusion criteria. Both groups demonstrated significant improvement on Nurick and JOA scores postoperatively. Two patients in the laminectomy alone group required a subsequent one-level anterior cervical discectomy and fusion for onset of postoperative neck pain, without neurological symptoms or new deficits in the follow up period. There was no difference in rates of post-operative kyphosis between the groups. In appropriately selected patients without pre-operative kyphosis or abnormal motion on flexion-extension films, cervical laminectomy remains a safe and effective treatment option.