High-volume Surgeons Research Articles

Association Between Surgeon Volume and Patient Outcomes After Elective Patellofemoral Arthroplasty: A Population-Based Cohort Study Using Data from the National Joint Registry and Hospital Episode Statistics for England.

The objective of this study was to determine the relationship between surgical volume and patient outcome after arthroplasty of the patellofemoral joint, to improve patient outcomes and inform future resource planning. All patellofemoral arthroplasty (PFA) records in the National Joint Registry from January 2003 to December 2021 were linked to the Hospital Episode Statistics database for England. The main outcome measure was revision surgery. Secondary outcome measures were serious adverse effects, patient selection characteristics, and implant designs used. Associations of early and late revision with surgical volume were examined based on surgical volume, and reasons for revision were explored. Of the knee arthroplasty surgeons in the database, 858 (26%) performed ≥1 PFA during the study period; 14,615 PFA cases were available for analysis. The modal caseload was 2 per year. High-volume surgeons were defined as surgeons performing >5 PFAs per year. The hazard ratio (HR) for a high-volume surgeon was 0.98 per additional PFA per year, and the patients treated by these surgeons had a lower risk of revision than than those treated by low-volume surgeons irrespective of the patient's age. High-volume surgeons were more likely to identify and treat patients with patellar disorders than low-volume surgeons (odds ratio [OR], 1.34; 95% confidence interval [CI], 1.09 to 1.77; p < 0.05), and their patients were less likely to have serious adverse effects as these surgeons' experience increased (OR per additional PFA per year, 0.97; 95% CI, 0.95 to 0.99; p = 0.02). Inlay implants had a higher risk of revision than onlay implants irrespective of surgical experience: for low-volume surgeons, inlays had an HR of 1.68 (95% CI, 1.23 to 2.30; p = 0.01), and for high-volume surgeons, inlays had an HR of 2.38 (95% CI, 1.83 to 3.11; p = 0.01). The most common reason for revision was progressive osteoarthritis. High-volume surgeons' patients were less likely than low-volume surgeons' patients to have an early revision (<2 years postoperatively) (OR, 0.72; 95% CI, 0.55 to 0.93; p < 0.05). An association was found between surgeons performing >5 PFAs per year and a lower revision rate. This study should inform surgical planning services to improve the outcomes of PFA. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Surgeon Volumes of Endovascular Thoracoabdominal Aneurysm Repairs, but not Juxtarenal Repairs, are Associated with Outcomes following Endovascular Repair of Thoracoabdominal Aneurysms.

Endovascular thoracoabdominal aortic aneurysm (eTAAA) repair remains one of the more technically challenging aspect of vascular surgery, with significant risk of mortality, spinal cord ischemia (SCI), and end organ damage. Although fenestrated devices are available for juxtarenal aneurysms, there are no commercially available eTAAA devices on the US market currently. We therefore studied how the volume of juxtarenal repairs would translate to outcomes of these more complicated aneurysms. We studied all eTAAA repairs (Crawford type 1-3) in the Vascular Quality Initiative from 2014-2021 and categorized surgeons into quartiles based on their average annual eTAAA volume and endovascular juxtarenal volume. Our primary outcome was thoracoabdominal life altering events (TALE-composite of perioperative death, stroke, permanent SCI and dialysis). We employed mixed effects logistic regression clustering by center and surgeon. We identified 5335 repairs from 607 surgeons, with annual average eTAAA volumes of 2,629 from 400 surgeons. Quartile 1 involved <2 repairs and quartile 4 involved >12 repairs per year. Repairs at higher quartiles were for larger aneurysms, more commonly employed staged repairs, utilized spinal drains, and more frequently utilized physician modified endografts, whereas low volume surgeons most commonly employed parallel grafting. Higher volume surgeons had overall shorter procedural times, fluoroscopy time, and less total contrast. Technical success similarly increased as procedure volume increased. In adjusted analyses, rates of perioperative death, TALE, stroke, acute kidney injury and major adverse cardiac events were all lower in the highest volume quartile compared to the lowest. However, after accounting for eTAAA volume, surgeon volume of endovascular juxtarenal repairs was not associated with any postoperative outcome, and there was no significant interaction between juxtarenal and eTAAA volume. Medium term mortality was lowest in patients treated in the top two quartiles of volume (HR 0.77 [0.61-0.97], P = .024. Surgeon eTAAA experience shows a strong volume-outcome effect on outcomes in the immediate post operative period and in permanent patient-centered outcomes. However, experience in less extensive aneurysms did not directly translate to thoracoabdominal aneurysms. Further study is needed to evaluate the role that commercial graft availability and repair type contributes to these findings.

Factors Associated with Increased Fluoroscopy Time During Elective Endovascular Abdominal Aortic Aneurysm Repair and its Utilization as an Indicator of Intraoperative and Postoperative Outcomes

This study explores the impact of prolonged fluoroscopy time (FT) on outcomes in endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAAs). While total operative time includes multiple variables, FT precisely captures the technical precision of the EVAR procedure. By examining the factors that extend FT, we aim to establish FT as a critical quality metric for evaluating surgical performance and predicting postoperative outcomes. A retrospective review of the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) was conducted (2003-2021). The FT was studied based on a median dichotomy of ≤18mins (Group I) and >18mins (Group II). Primary outcomes of in-hospital mortality and discharge status were studied, along with numerous secondary outcomes pertaining to systemic complications. Factors associated with more extended FT were also measured. All the variables examined in multivariate analyses were estimated in odds ratios, and a P-value of <0.05 was deemed significant for all the analyses performed. 41,841 patients were studied, of which 20,339 were categorized in Group I and 21,502 in Group II. The average fluoroscopy time in the selected patients was reported to be 23.2minutes. Patients in Group II generally had overall poorer health status with multiple comorbidities and on various medications. Aortic aneurysm parameters can influence the FT, including the greater aorta-neck angle, neck angle, neck diameter, and neck length. Patients treated by high-volume surgeons were observed to have less likelihood of prolonged FT. On trends analysis, it was observed that the FT has been consistent over the study period. Various factors can influence the FT in patients undergoing EVAR, including the patient characteristics and the complexity of the aneurysm. Identifying the risk factors associated with prolonged FT can help prepare the surgeons and devise ways to ensure a high quality of care, better risk stratification, and enhanced safety, especially for more prolonged exposure to radiation and contrast volumes.

Work Related Pain in Gynecologic Surgeons - A National Survey.

The objectives of the study are to 1) ascertain the prevalence of work-related pain amongst gynecologic surgeons, 2) describe risk factors and sequelae of pain and 3) assess the need for an ergonomic curriculum. Survey study. The survey was electronically administered. Gynecologic surgery subspecialists and fellows in training were included, as well as Ob/Gyn Specialists who perform gynecologic surgery. A 38-question anonymous survey was developed from available ergonomic literature and had three main sections 1) demographic information, 2) pain history and 3) ergonomic education. 305 gynecologic surgeons participated. 76.7% identified as female. Most respondents were Minimally Invasive Gynecologic Surgeons (64.6%) with a primary surgical modality of conventional laparoscopy (65.6%). 95.7% of respondents reported pain during or after surgery. Female surgeons (p = .018), shorter surgeons (OR = 2.4, 95% CI [1.1, 5.4]), and those with a smaller glove size (p = .025) were more likely to report severe pain. Surgeons who reported worse pain were more likely to seek treatment (p = .007) and take time off from operating (p < .001). 79.4% of respondents report engaging in a variety of interventions to treat surgery-related pain. Due to pain, 23.9% report changing surgical modality and 62.5% of surgeons are concerned about their ability to operate in the future. 61.3% of surgeons did not feel confident in their ability to ergonomically set up their operating room. 98.0% recommend formal ergonomic training for residents. Surgeons are at risk for work-related pain. Gynecologic surgeons are an understudied population with specific ergonomic challenges. In this national survey of high-volume gynecologic surgeons of various subspecialities, we report a high rate of surgery-related pain, significant clinical and nonclinical sequelae of pain, and demonstrate a need for implementing and improving ergonomic training for Obstetrics and Gynecology trainees.

Surgeon Experience May Predict Failure after Revision Total Hip Arthroplasty for Periprosthetic Fracture.

Periprosthetic fracture often requires revision hip arthroplasty. This study evaluated factors contributing to subsequent revisions and reoperations in patients who underwent revision hip arthroplasty for periprosthetic femur fracture. The authors hypothesized that surgeons who had higher revision volume would have decreased subsequent complications. A retrospective review of 84 revision hip arthroplasties for Vancouver B2 periprosthetic femur fractures performed at a single academic institution was conducted. Surgeons were categorized based on their reoperation volume: experienced (≥ 12 complicated hip reoperations annually) and less experienced (< 12 complicated hip reoperations annually). Univariable and multivariable analyses evaluated risk factors for all-cause revision. Survival analyses were performed using Cox Proportional Hazard modeling. Of the 84 patients, there were 8 (10%) revisions and 15 (18%) reoperations. Survivorship free of all-cause revision was greater for high-volume surgeons [Hazard Ratio [HR] 0.03 (0.00 to 0.43); P = 0.01]. Sub-analysis demonstrated that experienced surgeons had increased 5-year survivorship free of septic revisions [HR 0.03 (0.00 to 0.54); P = 0.02]. The multivariable analysis also demonstrated that extended oral antimicrobial prophylaxis was associated with 5-year septic reoperation-free survival [HR 0.03 (0 to 0.45); P = 0.01]; this only trended toward significance in 5-year septic revision-free survival [HR 0.04 (0.00 to 1.97); P = 0.11). There was no association between aseptic revision and surgeon experience in univariable or multivariable analysis. Experienced arthroplasty surgeons, as well as extended oral antibiotic prophylaxis, may improve patient outcomes when treating patients who have periprosthetic fractures requiring revision arthroplasty. Consideration should be given to call schedules and management of this vulnerable population.

A Comparison of Wound Related Complications Between Intramedullary and Lateral Plate Osteosynthesis After Fibula Osteotomy in the Lateral Approach Total Ankle Replacement.

Total ankle replacement (TAR) has evolved in the last decade from a procedure rife with complication and failure to a promising alternative to arthrodesis. The ability to maintain ankle joint range of motion is showing great promise in patient-reported outcomes, postsurgical pain, as well as long-term sequalae of joint fusion. Although TAR can be performed via either an anterior or lateral approach both with their own sets of benefits and potential complications, the consensus seems to be that one is no better than the other when performed by high-volume surgeons. Data were gathered over a 6-year period looking at an age- and gender-matched cohort of lateral approach TARs with either plate osteosynthesis or fibula nail fixation in the management of the fibula osteotomy and compared reoperation and infection rates with the working hypothesis that nail fixation would afford better outcomes. Secondary outcomes including rates of fibula union, tourniquet time as an adjunct to procedure length, and patient-reported outcome measures (PROMs) in the form of FAOS Quality scores were included. A total of 234 TARs were analyzed. Forty-five of these used intramedullary nail fixation (IM), and a control group of 45 plate osteosynthesis (PO) fixation cases was correlated. The Foot and Ankle International guidelines on reporting for complications arising from total ankle arthroplasty that resulted in reoperation were applied to the data set, and it was noted that 13 of 19 reoperations were noted in the PO group, which was statistically significant. Also of note, 12 of 16 patients treated with antibiotics, which included all those cases within the reoperation group, were noted to come from the PO group. This was also of statistical significance. Interestingly, the rate of fibula nonunion in the PO group was lower (8.88%) than that of the IM group (23.25%). Our results confirmed that the rates of reoperation and infection were statistically significantly improved with the use of nail fixation over plate fixation. This was tempered by a concerningly high nonunion rate. This article shows promising results for the use of a simple technique in improving long-term outcomes in ankle arthroplasty.

Immediate repair of the recurrent laryngeal nerve during thyroid surgery via a tension-free end-to-side anastomosis with the Vagus.

The unprecedented technical and technological evolution in thyroid surgery has labelled it as an extremely safe and efficient procedure, and indeed "typifies perhaps better than any other operation the supreme triumph of the surgeon's art."-William Halsted, 1852-1922. Surgeon's experience reflected by annual case load is the most important denominator in thyroid surgery. Nevertheless, even high-volume thyroid surgeons in high-volume centres are not immune to its complications. Despite the advances in surgical technology and techniques, recurrent laryngeal nerve (RLN) injury is still a wellknown complication of thyroid surgery. The considerable postoperative morbidity associated with it and its impact on the patient's overall quality of life make it a dreadful complication of thyroid surgery and a common cause of malpractice accusations. Intraoperative RLN reconstruction is not widely used in clinical practice, but the evidence so far makes it a viable and safe alternative to traditional techniques with better long-term results, as it prevents the occurrence of atrophy of the vocal cord and should be considered in the operating room if possible. Furthermore, immediate reconstruction of an intraoperatively detected RLN injury has been strongly recommended by the 2020 American Association of Endocrine Surgeons guidelines. After neurorrhaphy, RLN regeneration occurs but in a random, misdirected fashion resulting in simultaneous contraction of abductors and adductors. Therefore, normal vocal fold function/mobility is typically not restored. The objective of this technical note is to describe a novel immediate RLN repair technique that has a strong propensity to regenerate and reinnervate laryngeal muscles and potentially restore laryngeal mobility.

Permanent hypoparathyroidism following total thyroidectomy - Incidence and preventative strategies without imaging adjuncts.

Permanent hypoparathyroidism (pHypoPT) is the most common permanent complication of total thyroidectomy. We aim to describe the incidence and predictors of hypoparathyroidism in a consecutive series of patients treated in a high-volume centre and define strategies to reduce the risk of pHypoPT. 1182 patients who underwent total thyroidectomy between April 2018 and June 2022 were analyzed. Temporary hypoparathyroidism (tHypoPT) was defined as PTH <0.4​pmol/L (<4​pg/mL) at day one post-operatively, or clinical or biochemical evidence of hypocalcemia. pHypoPT was defined as an ongoing need for calcitriol supplementation to maintain normocalcemia at 12 months. Symptomatic tHypoPT (OR 43.97, p​<​0.001) and number of parathyroid glands in the operative specimen (OR 2.31, p​=​0.022) were also significantly associated with pHypoPT. Biochemical tHypoPT occurred in 205 (17.4​%) patients whilst pHypoPT occurred in 6 (0.5​%) patients. On multivariate analysis, parathyroid auto-transplantation (PA) independently reduced the risk of pHypoPT (OR 0.04, p​=​0.004). The risk of pHypoPT after total thyroidectomy is 0.5​% when performed by high-volume surgeons. PA represents an important technique that reduces the risk of pHypoPT.

The Association Between Surgeon Volume and Dislocation After Total Hip Arthroplasty: A Nationwide Evaluation of 5,106 Orthopaedic Surgeons.

The relationship between surgeon volume and risk of dislocation after total hip arthroplasty (THA) is debated. This study sought to characterize this association and assess patient outcomes using a nationwide patient and surgeon registry. The Premier Healthcare Database was queried for adult primary elective THA patients from January 1, 2016, to December 31, 2019. Annual surgeon volume and 90-day risk of dislocation were modeled using multivariable logistic regression with restricted cubic splines. Bootstrap analysis identified a threshold annual case volume, corresponding to the maximum decrease in dislocation risk. Surgeons with an annual volume greater than the threshold were deemed high volume, and those with an annual volume less than the threshold were low volume. Each surgeon within a given year was treated as a unique entity (surgeon-year unit). 90-day complications of patients treated by high-volume and low-volume surgeons were compared. From 2016 to 2019, 352,131 THAs were performed by 5,106 surgeons. The restricted cubic spline model demonstrated an inverse relationship between risk of dislocation and surgeon volume (threshold: 109 cases per year). A total of 9,967 (87.8%) low-volume surgeon-year units had individual dislocation rates lower than the average of the entire surgeon cohort. Patients treated by high-volume surgeons had decreased risk of dislocation (adjusted odds ratio [aOR], 0.60; 95% CI, 0.54 to 0.67), periprosthetic fracture (aOR, 0.87; 95% CI, 0.76 to 0.99), periprosthetic joint infection (aOR, 0.63; 95% CI, 0.56 to 0.69), readmission (aOR, 0.70; 95% CI, 0.67 to 0.73), and in-hospital death (aOR, 0.60; 95% CI, 0.46 to 0.80). While most of the low-volume surgeons had dislocation rates lower than the cohort average, increasing annual surgeon case volume was associated with a reduction in risk of dislocation after primary elective THA. Level IV.

Thyroid cancer quality of care indicators: A scoping review.

Thyroid cancer, the most common endocrine malignancy, has highly variable practice patterns. This scoping review aimed to identify quantitative and qualitative quality of care indicators (QIs) essential for providing optimal care in thyroid cancer management. A comprehensive search across MEDLINE, EMBASE, PubMed, and Web of Science identified QIs defining structures, processes, and outcomes in five care phases: pre-diagnosis, diagnosis, treatment, post-treatment surveillance, and end-of-life care. Of the 3,143 articles screened, 36 were included, yielding 135 unique QIs. Key diagnostic QIs were the use of a standardized ultrasound reporting system (n​=​4), diagnostic fine needle aspiration biopsy (FNAB) (n​=​3), and FNA cytology reporting with the Bethesda System (n​=​3). Common treatment QIs included thyroidectomy by high-volume surgeons (≥10-32 cases/year) (n​=​7), preoperative voice assessment for high-risk patients (n​=​4), and recurrent laryngeal nerve monitoring (n​=​3). Serum thyroglobulin (Tg) monitoring was the primary post-treatment QI for recurrence (n​=​2). Developing an evidence-based QI list can identify care gaps, direct targeted interventions, promote care standardization, and improve outcomes for thyroid cancer patients.

Incidence of Incisional Hernias after Single-Port Versus Multi-Port Robotic Radical Prostatectomy.

Purpose: To determine if single-port robotic-assisted radical prostatectomy (SP-RARP) has higher rates of incisional hernias when compared with multi-port robotic-assisted radical prostatectomies (MP-RARP). Materials and Methods: A retrospective, single-institution review of all consecutive robotic prostatectomy cases between January 2017 and December 2022. Analyzed multi-port and single-port robotic prostatectomies performed by two high-volume surgeons. Measured primary outcome for the development of incisional hernias, as defined by computed tomography imaging and clinical documentation. Multivariable logistic regression was used to determine the effect of the single-port approach on incisional hernia outcomes. Results: A total of 493 patients were included in the study (320 SP-RARPs and 173 MP-RARPs). The overall incisional hernia rate was 8.5% (SP-RARP 8.1% vs MP-RARP 9.2%, p = 0.669). A median follow-up time was 16.6 months and a median time from procedure to hernia diagnosis was 7.4 months. SP-RARP had shorter OR time than the MP-RARP (236 minutes vs 276 minutes, p < 0.001). Patients who developed hernias had higher body mass index (BMIs) than those who did not (30.7 vs 29, p = 0.009). Multivariable logistic regression analysis revealed that patients with higher BMI (odds ratio [OR] 1.07, 95% confidence interval [CI] 1.01-1.14) and a history of prior operation (OR 2.23, 95% CI 1.71-4.29) were more likely to develop incisional hernias. Cox regression analysis accounting for the difference in follow-up period demonstrated that SP-RARP 3.4× more likely to develop incisional hernias than MP-RARP (hazard ratio 3.38, 95% CI 1.50-7.58). Conclusions: Patients with higher BMIs and prior history of abdominal surgeries are at increased risk of developing postoperative incisional hernias. SP-RARP procedures confer a higher risk of postoperative incisional hernias.

Surgeon Adoption of Immediate Sequential Bilateral Cataract Surgery in the United States from 2018 to 2022: Immediate Sequential Bilateral Cataract Surgery.

To assess 5-years trends in the rate of immediate sequential bilateral cataract surgery (ISBCS) and surgeon characteristics associated with performing ISBCS. 100% Medicare Fee-for-service beneficiaries from 2018-2022. Cross-sectional study. ISBCS cases were identified among patients aged ≥ 65 years undergoing bilaterally performed cataract surgery (BPCS). Cochrane Armitage trend test was used to assess patient and surgeon characteristics over time. Multivariable logistic regression was used to evaluate surgeon characteristics associated with performing ISBCS. Among 1,190,169 BPCS, 3,954 (0.33%) were ISBCS. Quarterly ISBCS rate increased from 2.12 to 5.5 per 1,000 BPCS (p<0.001). Among 10,290 surgeons, 1,119 (10.87%) performed ISBCS on some patients. Proportion of surgeons performing ISBCS per 1,000 cataract surgeons increased from 15.63 during the first quarter of 2018 to 26.55 during the last quarter of 2022 (p<0.001). Among the ISBCS surgeons, the proportion of ISBCS cases per 1,000 BPCS doubled from 17.20 in 2018 to 35.50 in 2022 (p<0.001). On multivariable analysis, surgeons in the highest surgical volume quartile (OR: 1.21; 95% CI: 1.01-1.45; Ref: lowest quartile), recent graduates (0-10 years OR: 2.43, 95% CI: 1.87-3.15; Ref: ≥ 31 years) and surgeons in West (OR: 2.408, 95% CI: 2.052-2.826; Ref: South) had higher odds of performing ISBCS. There was an increased rate of ISBCS possibly suggesting greater interest among patients and surgeons. Although the overall ISBCS rate remained low, the number of surgeons performing ISBCS increased. Higher volume surgeons, recent graduates, and those practicing in the West were more likely to perform ISBCS.

Cataract surgical training: Analysis of the results of the European Board of Ophthalmology survey in the Swiss cohort.

This study, part of a series, analyses the Swiss cohort from an EBO survey on cataract surgery training in Europe, focusing on Switzerland's unique program. The survey identifies two models: training all residents in surgery, and a "high-volume surgeon" model where only some learn CS post-residency. This study analyses the survey results of Swiss participants in the EBO examinations (2018-2022) and compared them with the most important cohorts (Germany, France and Spain). Out of 251 respondents, 87 (34.7%) answered the questionnaire. Most (70.1%) had taken the EBO exam between 2021-2022, with the majority of study participants being men (55.2%) with a median age of 34 years and came from 12 different cantons. Two third (68.8%) of respondents had not performed any steps of cataract surgery on patients during their residency. Notably, 22.1% stated that they had carried out 10 or more training sessions on virtual reality simulator, 5.8% on synthetic eyes and 21% on animal eyes. A notable discrepancy was observed between participants with 10 or more training sessions and those without specific training in four key areas: self-assessed confidence and ability to perform cataract surgery (p = 0.006), management of challenging cases (p = 0.027), handling complications like posterior capsular tear (p = 0.031) and in performing corneal sutures (p = 0.023). Switzerland fits into the "high-volume surgeon" model group; extensive simulation-based training there significantly boosts self-confidence in performing CS, an effect less noticeable in countries offering hands-on training during residency.

Association Among Surgeon Volume, Surgical Approach, and Uterine Size for Hysterectomy for Benign Indications.

To assess the relationship between surgeon volume and surgical approach for patients undergoing hysterectomy for benign indications among uteri of varying sizes. This was a retrospective cohort study of patients who underwent hysterectomy for benign indications from 2012 to 2021 within the Michigan Surgical Quality Collaborative registry. For each hysterectomy, the relative annual volume of the performing surgeon was assessed by calculating the proportion of hysterectomy cases contributed by the surgeon each calendar year relative to the total number of hysterectomies in the registry for that year. Hysterectomies were stratified into tertiles: those performed by low-volume surgeons, intermediate-volume surgeons, and high-volume surgeons. Uterine size was represented by the uterine specimen weight and categorized to facilitate clinical interpretation. Multivariable logistic regression models were developed incorporating interaction terms for surgeon volume and uterine size to explore potential effect modification. A total of 54,150 hysterectomies were included. Hysterectomies performed by intermediate- and high-volume surgeons were more likely to be performed through a minimally invasive approach compared with those performed by low-volume surgeons (intermediate-volume: adjusted odds ratio [aOR] 1.68, 95% CI, 1.47-1.92; high-volume: aOR 2.14, 95% CI, 1.87-2.46). Moreover, this likelihood increased with increasing uterine weight. For uteri weighing between 1,000 g and 1,999 g, the odds of minimally invasive approach was significantly higher among intermediate-volume surgeons (aOR 3.38, 95% CI, 2.04-5.12) and high-volume (aOR 9.26, 95% CI, 5.64-15.2) surgeons, compared with low-volume surgeons. After including an interaction term for uterine weight and surgeon volume, we identified effect modification of surgeon volume on the relationship between uterine size and choice of minimally invasive surgery. For uteri up to 3,000 g in weight, hysterectomies performed by high-volume surgeons have a higher likelihood of being performed through a minimally invasive approach compared with those performed by low-volume surgeons.

Same-day parathyroidectomy for primary hyperparathyroidism -an over 20-year practice.

There has been a shift in recent years toward same-day parathyroidectomies due to the decrease in mutual costs with few significant differences in postoperative morbidity or mortality. We sought to determine if demographics, preoperative patient risk factors, or comorbidities were associated with a patient's likelihood of having same-day or inpatient surgery. A prospective database of parathyroid operations from 2001 to 2022 (n=2948 patients) was reviewed for surgeries completed for primary hyperparathyroidism. Patients were categorized as same-day or inpatient surgery; demographics, risk factors, and co-morbidities were examined and differences across practice patterns during the 21-year period were studied and also analyzed in a subset of patients from 2013 to 2022. In a recent subset of patients from 2013 to 2022, patients having inpatient surgery were more likely to be Black and use anticoagulation or antiplatelet therapy. Multivariable regression confirmed increased odds of aging and black patients requiring inpatient parathyroidectomy. Compared to 2001-2003, there was a significantly increased proportion of patients undergoing same-day surgery; compared to 2010-2012, there was a similar proportion of patients undergoing outpatient surgery between 2013 and 2018, and there was an increased proportion from 2019 through 2022. Same-day parathyroidectomies have been shown to be safe and has become the typical practice for high-volume parathyroid surgeons over the last decade. Complications such as postoperative hematoma or hypocalcemia were previously shown to be incompletely mitigated by increased LOS or inpatient surgery, although demographics are considered to increase the odds of inpatient parathyroidectomy.

Posterior retroperitoneal adrenalectomy for metastatic disease: a multi-site Australian series.

Posterior retroperitoneoscopic adrenalectomy (PRA) for isolated adrenal metastasis is minimally invasive, may prolong survival and improve quality of life. The current evidence base is scant. A multi-site retrospective analysis of all cases of PRA for adrenal metastasis between 2011 and 2023, by four high-volume adrenal surgeons was performed. Perioperative morbidity, disease-free and survival outcomes were reported. Of 51 patients, 34(67%) male, mean age 63 ± 12 years, mean BMI 28; 49 PRAs for adrenal metastatectomy were completed (one abandoned due to tumour unresectability, one conversion to anterior laparoscopic approach) across 11 hospitals (49% public). Primary tumours included: 11 colorectal, 11 renal, 8 lung, 6 hepatocellular, 4 sarcoma, 3 breast, 2 melanoma, 2 ovarian and 1 each of pancreatic, oesophageal, testicular and prostate cancer. There were 12 synchronous (<6 months) and 39 metachronous (>6 months after primary diagnosis) tumours; 21 (42%) left sided, none bilateral. Mean operative time was 95 ± 34 minutes, mean maximal tumour diameter was 34 mm ± 13 mm and median length of hospitalization 1 ± 1 days. There were 8 (16%) complications; 1 ICU admission, 1 re-admission for pneumonia and 6 Clavien-Dindo grade I complications. There were 10 (20%) mortalities and a median overall survival of 29 months (range 7-123, n = 41). Disease recurred in 15 (40%) patients (n = 37), with a median disease-free interval of 18 months (range 1-68). Port site recurrence occurred in 2 patients, both simultaneously with disseminated metastases. In carefully selected patients with adrenal metastases, PRA by high-volume adrenal surgeons has minimal morbidity and short hospitalization. Surgery should be considered prior to local ablation.

The Relationship Between Hospital Safety-Net Burden on Outcomes for High-Volume Thyroid Cancer Surgeons.

Background: Higher center and surgeon volume correspond to better outcomes for patients with thyroid cancer. This study aims to investigate how a hospital's safety-net burden, the proportion of a hospital's patients who are insured by state Medicaid plans or are uninsured, influences the outcomes of high-volume (HV) surgeons. Methods: We performed a retrospective cohort study of all patients who underwent surgery for thyroid cancer in California from 1999 to 2017. We stratified treating facilities by the proportion of Medicaid-type and indigent payors into safety-net burden quartiles. We compared the perioperative and oncologic outcomes of HV surgeons (annual case volume ≥10) for patients undergoing total thyroidectomy across safety-net burden quartiles. A mixed-effects regression model controlled for surgeon random effects and fixed effects of patient and tumor characteristics. Results: Our sample comprised 42,347 patients (78% female, median age 50), of whom 13,848 (32%) were treated by HV surgeons (n = 276). Compared to patients of lower-volume surgeons, patients of HV surgeons were more likely to be White, from the upper quartiles of socioeconomic status and well insured (all p < 0.001). HV surgeons in each hospital's safety-net burden quartile displayed similar case number distributions. Compared to patients treated by HV surgeons at Q1 (lowest safety-net burden) hospitals, those treated by HV surgeons at Q4 (highest safety-net burden) hospitals had higher absolute risks of endocrine complications (+7%, p = 0.007), airway complications (+6%, p = 0.004), disease-specific mortality (+1.3%, p = 0.046), and all-cause mortality during the study period (+3%, p = 0.046) in multivariable analysis. Conclusion: The performance of HV thyroid cancer surgeons differs by a hospital's safety-net burden, with patients treated at high safety-net burden hospitals experiencing higher rates of operative complications, disease-specific mortality, and all-cause mortality. Having a HV surgeon alone may be insufficient to provide optimal short- and long-term outcomes for patients with thyroid cancer.

Impact of Surgeon Volume on Perioperative Complications and Survival to Total Hip Arthroplasty Following Femoral Head Core Decompression

Introduction: Core decompression is a minimally invasive procedure considered in the treatment of early-stage femoral head osteonecrosis. This procedure is theorized to relieve vascular pressure and promote angiogenesis. Although a less invasive procedure, there are considerations related to learning curve, technique variations, etc. that may affect postoperative complications and longer term adverse events. Methods: Adult patients who underwent core decompression with a diagnosis of femoral head osteonecrosis were identified in the 2010-Q3 2021 PearlDiver M157 database. Core decompression surgeon volumes over the entire study period were assessed and divided into ranges: low (&lt;5 procedures), medium (5 ≤ x ≤ 19 cases), and high (&gt;19 cases) volumes. A 1:1:1 match based on age, sex, and Elixhauser Comorbidity Index was completed. Rates of 90-day complications were compared with univariable and multivariable analyses. Survival to total hip arthroplasty (THA) and to subsequent hip fracture at both 2 and 5 years were compared by Kaplan-Meier survival analysis. Results: The low-volume, medium-volume, and high-volume surgeon groups made up 87.5%, 11.9%, and 0.2% of core decompression volume, respectively. This was indicative of 6333 patients undergoing core decompression, and matching based on the surgeon-volume category led to 486 patients per group. No statistically significant differences were observed in shorter term complications and survival to THA or hip fracture at 2 or 5 years. Conclusion: Core decompression is a treatment option often considered for early-stage osteonecrosis. Critically, no differences were found in rates of any assessed complications between the surgeon-volume matched cohorts. These findings suggest that core decompression is a relatively safe procedure for surgeons of varying volume with this technique. Furthermore, this study suggests that higher volume surgeons are not conducting the procedure with expanded indications that might result in greater rates of conversion to THA.

Age and Surgical Volume Impact Likelihood and Technique of Lateral Extraarticular Augmentation During Primary Anterior Cruciate Ligament Reconstruction.

To evaluate the current utilization trends of practicing surgeons performing and lateral extra-articular augmentation (LEA) at the time of primary anterior cruciate ligament reconstruction (ACLR). The survey was distributed via e-mail in August 2023 to members of the Arthroscopy Association of North America who identified as knee surgeons and was available online on the Arthroscopy Association of North America website from January to September 2023. The 18-question survey was designed regarding surgeons' surgical utilization patterns of LEA during ACLR. Survey questions were created based on prior published research and recommendations regarding indications for LEA, as well as surgeon factors that have been shown to influence operative decision-making. Data were analyzed by surgeon geographics, procedure preferences, patient-based decision factors, surgeon-based decision factors, and surgeon age. The survey was completed by 165 sports medicine surgeons who identified as arthroscopic knee surgeons. Majority practice types included private practice (42.1%), academic centers (26.8%), and hospital systems (20.7%). Surgeon age was 50.36 years (range, 33-77 years). In total, 6.8% perform <20 ACLRs per year, 30.2% perform 20 to 40, 26.5% perform 40 to 60, 10.5% perform 60 to 80, and 25.9% perform >80 per year. Of the surgeons, 79.4% conduct LEA, with the modified Lemaire being the most common technique (43.5%), followed by other lateral extra-articular tenodesis (LET) techniques (42.0%) and anterolateral ligament reconstruction (ALL) (27.5%). Some surgeons (14.5%) use more than 1 technique. High-volume (>60 ACLR/year) surgeons were more likely to perform LEA (23.1% vs 10.0%, P= .061) and more likely to perform anterolateral ligament reconstruction (32.2% vs 16.5%, P= .034). Younger surgeons (age <50) were more likely to use the modified Lemaire (44.4% vs 24.3%, P= .014). Decision-making to perform LEA weighted highly on patient hyperlaxity, pivot-shift severity, knee hyperextension, sport type, and age, respectively. The most reported surgeon-related factor influencing LEA utilization was training bias (38.9%). Most orthopaedic surgeons with diverse geographics, demographics, practice setting, and ACLR volume perform LEA. Younger surgeons perform more frequently LEA, and surgeons admit to training bias in decision-making. Patient factors highly impacting utilization of LEA are hyperlaxity, pivot-shift severity, knee hyperextension, sport, and age. LEA procedures for ACLR have become increasingly utilized in populations at high risk for rerupture. However, there is not currently a clear standard of care with regard to LEA procedure type or indications for augmentation.

Lower Surgical Volume Reduces the Odds of Performing Meniscus Repair for Tears During Primary Anterior Cruciate Ligament Reconstruction

To investigate the influence of surgical volume, and various patient-, injury-, and surgery-related factors, on meniscal treatment strategies in primary anterior cruciate ligament reconstruction (ACLR). This retrospective cohort study analyzed patients with concomitant meniscal injuries undergoing primary ACLR, from 2008 to 2022, using data from the Swedish National Knee Ligament Registry. Surgeons and clinics were stratified by total caseload (cutoff: 50 ACLRs/surgeon, 500 ACLRs/clinic) and annual volume (cutoff: 29 ACLRs/year/surgeon, 56 ACLRs/year/clinic). To assess factors influencing medial meniscus or lateral meniscus repair, adjusted multivariable logistic regression was conducted, with results presented as odds ratios (OR) and 95% confidence intervals (CI). In total, 20,699 patients undergoing primary ACLR with concomitant meniscal injuries were included. Lower percentages of meniscus repair were seen among surgeons with low caseload and annual volume (LCLV) (13.3%-20.8%) compared with high caseload and annual volume (HCHV) surgeons (19.0%-29.8%), and at LCLV clinics (11.1%-18.3%) compared to HCHV clinics (21.5%-33.8%), all P < .001. Significantly decreased odds of medial meniscus repair were seen for patients operated on by LCLV surgeons (OR 0.82, 95% CI 0.70-0.96; P= .015) or at LCLV clinics (OR 0.56, 95% CI 0.50-0.64; P < .001. Similar results were seen for lateral meniscus repair with LCLV surgeons (OR 0.83, 95% CI 0.69-1.01; P= .067) and LCLV clinics (OR 0.62, 95% CI 0.53-0.72; P < .001). Additionally, younger age, female sex, shorter time from injury to surgery, and ACLRs performed more recently were associated with increased odds of repair. Lower surgical volume significantly decreased the rates and odds of performing meniscal repair during primary ACLR. In contrast, ACLRs performed during more recent years, younger age, female sex, shorter time from injury to surgery, absence of chondral injuries, and injuries sustained during nonpivoting activities, positively influenced meniscal preservation. Level III, retrospective cohort study.