Surgeon Preference Research Articles

Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty.

Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty.

Paper 07: Postoperative Opioid Usage and Disposal Strategies Following Outpatient Arthroscopic Sports Medicine Procedures: A Prospective Observational Study

Objectives: While several studies have noted that patients are routinely over-prescribed opioids, few have reported usage following arthroscopic surgery. Nearly 2 million arthroscopic procedures are performed annually, and one study estimates that opioids are prescribed in excess in 88% of patients recovering from arthroscopic knee surgery. Such surplus of postoperative opioid prescription creates a conundrum, as many patients do not appropriately dispose of unused opioid pills, and the majority of recreational opioid users obtain these medications from friends or family. The objectives of this study were to determine opioid consumption, utilization of total prescription, and allocation for unused opioids following five common arthroscopic surgeries. Methods: This study is a prospective trial enrolling patients between the ages of 15-40 who were scheduled to undergo elective anterior cruciate ligament (ACL) reconstruction, labral repair of the hip or shoulder, meniscectomy, or meniscal repair. Patients were prescribed either 5-325 hydrocodone-acetaminophen or 5-325 oxycodone-acetaminophen based on surgeon preference. Patients completed a daily opioid usage survey during the 2-week postoperative period. In addition, patients completed a survey on postoperative day 21 inquiring about continued opioid use and medication disposal, if applicable. Opioid medication consumption was converted to morphine milliequivalents (MME) where one 5 mg oxycodone pill is equivalent to 7.5 MME and one 5 mg hydrocodone pill is equivalent to 5.0 MME. T-tests or Mann-Whitney U tests were used to calculate differences between continuous data. Chi-Square or Fisher’s Exact were used for categorical data. Results: Of the 200 patients enrolled in the study, 100 (50%) underwent ACL reconstruction, 26 (13%) underwent arthroscopic hip labral repair, 37 (19%) underwent arthroscopic shoulder labral repair, 23 (12%) underwent meniscectomy, and 14 (7%) underwent meniscal repair. The mean MME consumption in the 14 days following each procedure was calculated: ACL reconstruction (88.9), hip arthroscopy (84.8), shoulder arthroscopy (55.5), meniscectomy (24.3), and meniscal repair (31.2). This corresponded to a utilization rate of 40.4%, 36.5%, 40.7%, 37.4%, and 34.6% respectively (Table 1). Mean MME consumption was greatest on postoperative day 1 in all procedures, and only 6.6% of patients reported continued opioid use in the third postoperative week. Of the 141 patients available for follow up at 3 weeks, 113 reported having opioid medication remaining. Of the patients with remaining medication, 25.6% intended to keep their medication for future use (Figure 2). Conclusions: The results of our study indicate that patients who undergo the aforementioned arthroscopic procedures consume a mean of 70 MME in the 2-week postoperative period, translating into an average of 9-14 pills consumed, depending on medication prescribed. Few patients reported requiring opioid medication after 2 weeks postoperatively. Patients undergoing ACL reconstruction and hip labral repairs consumed the highest MME, followed by shoulder labral repair patients who consumed approximately 3 times more opioids than primary meniscal procedures. Approximately 65% of total opioids prescribed went unused, and over one fourth of patients intended to keep their remaining medication for future usage. [Table: see text]

Biomechanical design optimization of distal femur locked plates: A review.

Clinical findings, manufacturer instructions, and surgeon's preferences often dictate the implantation of distal femur locked plates (DFLPs), but healing problems and implant failures still persist. Also, most biomechanical researchers compare a particular DFLP configuration to implants like plates and nails. However, this begs the question: Is this specific DFLP configuration biomechanically optimal to encourage early callus formation, reduce bone and implant failure, and minimize bone "stress shielding"? Consequently, it is crucial to optimize, or characterize, the biomechanical performance (stiffness, strength, fracture micro-motion, bone stress, plate stress) of DFLPs influenced by plate variables (geometry, position, material) and screw variables (distribution, size, number, angle, material). Thus, this article reviews 20 years of biomechanical design optimization studies on DFLPs. As such, Google Scholar and PubMed websites were searched for articles in English published since 2000 using the terms "distal femur plates" or "supracondylar femur plates" plus "biomechanics/biomechanical" and "locked/locking," followed by searching article reference lists. Key numerical outcomes and common trends were identified, such as: (a) plate cross-sectional area moment of inertia can be enlarged to lower plate stress at the fracture; (b) plate material has a larger influence on plate stress than plate thickness, buttress screws, and inserts for empty plate holes; (c) screw distribution has a major influence on fracture micro-motion, etc. Recommendations for future work and clinical implications are then provided, such as: (a) simultaneously optimizing fracture micro-motion for early healing, reducing bone and implant stresses to prevent re-injury, lowering "stress shielding" to avoid bone resorption, and ensuring adequate fatigue life; (b) examining alternate non-metallic materials for plates and screws; (c) assessing the influence of condylar screw number, distribution, and angulation, etc. This information can benefit biomedical engineers in designing or evaluating DFLPs, as well as orthopedic surgeons in choosing the best DFLPs for their patients.

The Concept of Scaffold-Guided Bone Regeneration for the Treatment of Long Bone Defects: Current Clinical Application and Future Perspective.

The treatment of bone defects remains a challenging clinical problem with high reintervention rates, morbidity, and resulting significant healthcare costs. Surgical techniques are constantly evolving, but outcomes can be influenced by several parameters, including the patient's age, comorbidities, systemic disorders, the anatomical location of the defect, and the surgeon's preference and experience. The most used therapeutic modalities for the regeneration of long bone defects include distraction osteogenesis (bone transport), free vascularized fibular grafts, the Masquelet technique, allograft, and (arthroplasty with) mega-prostheses. Over the past 25 years, three-dimensional (3D) printing, a breakthrough layer-by-layer manufacturing technology that produces final parts directly from 3D model data, has taken off and transformed the treatment of bone defects by enabling personalized therapies with highly porous 3D-printed implants tailored to the patient. Therefore, to reduce the morbidities and complications associated with current treatment regimens, efforts have been made in translational research toward 3D-printed scaffolds to facilitate bone regeneration. Three-dimensional printed scaffolds should not only provide osteoconductive surfaces for cell attachment and subsequent bone formation but also provide physical support and containment of bone graft material during the regeneration process, enhancing bone ingrowth, while simultaneously, orthopaedic implants supply mechanical strength with rigid, stable external and/or internal fixation. In this perspective review, we focus on elaborating on the history of bone defect treatment methods and assessing current treatment approaches as well as recent developments, including existing evidence on the advantages and disadvantages of 3D-printed scaffolds for bone defect regeneration. Furthermore, it is evident that the regulatory framework and organization and financing of evidence-based clinical trials remains very complex, and new challenges for non-biodegradable and biodegradable 3D-printed scaffolds for bone regeneration are emerging that have not yet been sufficiently addressed, such as guideline development for specific surgical indications, clinically feasible design concepts for needed multicentre international preclinical and clinical trials, the current medico-legal status, and reimbursement. These challenges underscore the need for intensive exchange and open and honest debate among leaders in the field. This goal can be addressed in a well-planned and focused stakeholder workshop on the topic of patient-specific 3D-printed scaffolds for long bone defect regeneration, as proposed in this perspective review.

Access to the upper third of the face: a literary review of indications, techniques, and intercurrences

Due to its location, anatomy, and projection in the upper third of the face, the frontal bone is frequently affected by trauma of different intensities that result in fractures. Access to the upper third of the face for the correct reduction and stabilization of the trauma requires an extensive approach. The main alternatives for correct exposure are coronal and transcutaneous incisions. The coronal incision is the incision of choice, as it allows us to adequately approach important structures related to fractures of the frontal bone. The transcutaneous incisions, these incisions comprise the region of the eyebrow, upper eyelid, eyebrow, and gull-wing incision and, when present, lacerations in the soft tissue of the trauma itself can be used as access to the fractures. The present work aimed to describe, through a literature review, the accesses to the upper third of the face, as well as to report the techniques and intercurrences. Even though it is the main choice for coronal access, it can cause alopecia, loss of sensitivity, compromised aesthetics, muscle depression, possible need for postoperative blood transfusion, facial nerve deficit, and supratrochlear deficit, among others. The alternatives are transcutaneous incisions, these incisions include the region of the eyebrow, upper eyelid, eyebrow, and gull-wing incision and, when present, lacerations in the soft tissue of the trauma itself can be used as access to the fractures. It was concluded that although coronal access is the main choice, the choice of incision depends on the location of the fracture, the presence of laceration, its extension, its relationship with other fractures, and surgeon preference, in addition to aesthetic factors.

Grafts vs. flaps: a comparative study of Bracka repair and staged transverse preputial island flap urethroplasty for proximal hypospadias with severe ventral curvature.

Bracka repair and staged transverse preputial island flap urethroplasty are both significant methods in treating proximal hypospadias. They utilize the flap and graft techniques, respectively, to achieve a satisfactory success rate. This study aimed to compare the outcomes of these 2 methods in the treatment of proximal hypospadias with severe ventral curvature. We retrospectively analyzed 117 cases of proximal hypospadias with severe ventral curvature who had undergone either Bracka repair (n = 62) or staged transverse preputial island flap urethroplasty (n = 55). All operations were performed by a single surgeon, and the choice of method was determined by the surgeon's preference based on his experience. Cosmetic outcome was evaluated with Pediatric Penile Perception Score (PPPS). Patients' characteristics including age, penis length, glans diameter, length of the urethral defect and ventral curvature degree, cosmetic outcomes, and complication rates were all compared. There was no significant difference in age, penis length, glans diameter, length of the urethral defect, or ventral curvature degree. In the Bracka group, there were 5 patients with fistula, 1 patient with stricture, and 1 case of dehiscence. In the staged transverse preputial island flap urethroplasty group, there were 4 patients with fistula, 1 with stricture, and 2 with diverticulum. The scores of shaft skin and general appearance were consistently higher in the Bracka group than in the staged transverse preputial island flap urethroplasty group. The differences in complication rate and cosmetic outcome were not statistically different (P > 0.05). Bracka repair and staged transverse preputial island flap urethroplasty are both satisfactory staged surgical options for proximal hypospadias with severe ventral curvature and have similar complication rates. Bracka repair may create a better appearance, but more studies are needed to confirm this finding. Pediatric surgeons should consider additional factors, such as the patient's specific condition, parents' inclination, and personal experience, rather than safety, to make the best choice between the 2 methods.

AR visualizations in laparoscopy: surgeon preferences and depth assessment of vascular anatomy

Introduction: This study compares five augmented reality (AR) vasculature visualization techniques in a mixed-reality laparoscopy simulator with 50 medical professionals and analyzes their impact on the surgeon. Material and methods: ​​The different visualization techniques’ abilities to convey depth were measured using the participant’s accuracy in an objective depth sorting task. Demographic data and subjective measures, such as the preference of each AR visualization technique and potential application areas, were collected with questionnaires. Results: Despite measuring differences in objective measurements across the visualization techniques, they were not statistically significant. In the subjective measures, however, 55% of the participants rated visualization technique II, ‘Opaque with single-color Fresnel highlights’, as their favorite. Participants felt that AR could be useful for various surgeries, especially complex surgeries (100%). Almost all participants agreed that AR could potentially improve surgical parameters, such as patient safety (88%), complication rate (84%), and identifying risk structures (96%). Conclusions: More studies are needed on the effect of different visualizations on task performance, as well as more sophisticated and effective visualization techniques for the operating room. With the findings of this study, we encourage the development of new study setups to advance surgical AR.

Sometimes Less Is More!

Commentary The thought-provoking and well-performed study by Lähdeoja et al. represents a retrospective review of 209 patients who sustained a proximal humeral fracture as adolescents and had an impressive follow-up ranging from 7 to 19 years and a thorough and rigorous methodology to assess outcomes. The authors did an outstanding job matching cohorts to make valid comparisons with a similar group without a fracture. The study found that patients who sustained a proximal humeral fracture as adolescents healed well and had good outcomes in long-term follow-up. The study also found no significant differences between patients treated operatively and those treated nonoperatively. It is well known that proximal humeral fractures heal well in young children; however, less is known in adolescents. A recent systematic review found that, since the 1946 inception date in the National Library of Medicine’s computer-based retrospective search service, there have only been 4 prospective cohort studies and 8 retrospective cohort studies examining proximal humeral fractures in children1. None has explicitly focused on fractures occurring during adolescence. The current study by Lähdeoja et al. will add to the growing mountain of evidence that shows that even adolescents do well after this kind of injury. Lähdeoja et al. believe that their findings will influence the practice of orthopaedics as they can help to guide the treatment of proximal humeral fractures in adolescence by using the idea that less is more and noting that most patients can be treated nonoperatively with minimally burdensome methods for the patients and that parents can be assured that the outcomes are good. However, one should note that the idea of less is more can have different interpretations. Dolly Parton once famously said, “People say that less is more, but I think more is more.” She was, of course, referring to the absurdity of noting that a qualifier (less) is opposite to its meaning. The architect Frank Lloyd Wright is correct in stating that “Less is more only when more is too much.” Based on the results of this study, a surgical procedure for proximal humeral fractures in adolescence seems “too much.” However, the incentive to operate in many health-care environments may create a substantial surgeon preference toward treating fractures operatively. There have been a decrease in some reimbursement schedules for orthopaedic procedures2 and a concern for surgeons being incentivized to perform more cases to maintain productivity goals3; decreased reimbursement is a known stressor contributing to surgeon burnout. From a purely orthopaedic viewpoint, this article confirms that nonoperative treatment yields similar or superior results to those of operative treatment of proximal humeral fractures in adolescents. This study comes from an economically highly developed Scandinavian country, Finland, where more than three-quarters of the population received health care through the public system, in 20194, higher than the mean of 71.7% for Organization for Economic Cooperation and Development (OECD) countries5. Finland is one of the most efficient public-sector health service producers, and its model should be applauded and analyzed for generalizability. To quote one final author, Yvon Chouinard, the founder of the apparel and equipment company Patagonia, in his book6, Let My People Go Surfing: The Education of a Reluctant Businessman, “The more you know, the less you need.” In the case of proximal humeral fractures in adolescence, the more we know and understand the long-term consequences of these injuries, the less we need to worry about treating them operatively.

Diaphragmatic plication: current evidence and techniques in the management of the elevated hemidiaphragm

: Diaphragm plication is the preferred surgical intervention for elevation of the hemidiaphragm. This can be a consequence of trauma, damage to the phrenic nerve, or congenital eventration. There are numerous surgical approaches to diaphragmatic plication including open thoracic, open abdominal, minimally invasive transthoracic, minimally invasive transabdominal, and robotic assisted. All approaches are acceptable practices, but there has been a shift to more minimally invasive and video-assisted approaches. In this clinical practice review, we have assessed the current evidence and techniques used for hemidiaphragm elevation. Most evidence assessing the various techniques comes in the form of case studies, case series, and small institutional studies. Video-assisted thoracoscopic surgery is a commonly employed technique associated with positive outcomes as evidenced by improvement of pulmonary function test following the procedure, fewer chest tube days, decrease in self-reported dyspnea, and short hospital stays. Laparoscopic plication is also an acceptable technique. Multiple case studies showed overall positive outcomes with limited morbidity. Robotic assisted approaches were also reviewed. These interventions were shown to improve spirometry values and dyspnea scores. Minimal data exist on open abdominal approaches, and there are not currently enough data to assess their effectiveness. Open thoracic approaches were associated with improvements in spirometry as well as dyspnea scores. All surgical approaches discussed are acceptable strategies for the treatment of the elevated hemidiaphragm. No one intervention appears to be superior, but minimally invasive approaches have become more popular. The success of these procedures is largely believed to be based on surgeon preference and level of expertise.

Duodenal de-rotation as a determinant step for management of high jejunal atresia: Proximal duodenal plication after resection of dilated dysmotile segments

BackgroundDue to its distal mechanical obstruction, dilated duodenum is present in almost all patients with high jejunal atresia (HJA). If the former problem, which causes duodenal dysmotility, is not handled appropriately, traditional management of HJA alone is usually associated with feeding intolerance and prolonged hospitalization. In the present introduced technique, when added to classic surgical management of HJA, satisfactory results would be obtained. MethodsNewborns with HJA in the vicinity of the ligament of Treitz were managed, since May 2015 till November 2021, by this procedure in sequence as follows: duodenal de-rotation (DD); resection of the dilated and patulous proximal jejunum along with resection of the dilated third and fourth portions of the duodenum (D3 & D4). The dilated first and second portions of the duodenum (D1 & D2) were managed by one of the following options: anterolateral plication (ALP) or anterolateral resection (ALR) (manually or by stapler) preceded or followed by duodeno-jejunostomy respectively. Finally, appendectomy is done and the right colon is positioned at the left side of the abdomen. ResultsTwelve patients were managed by this procedure, two of whom expired after the operation due to unrelated problems, thereby excluded from this series. In ten patients (2–4 days old babies, eight males, two females), ALP was done in four, while six others were managed by ALR (depending on the surgeon preferences, three by stapler, three by manual resection). All these patients had an uneventful recovery. The first feeding could be tolerated ranging from 4 to 6 days after the operation; on average one day earlier in ALP patients. Post-operative length of hospitalization was 6–13 days (on average, 7 and 9.3 days in ALP and ALR groups, respectively). Regardless of the type of operation in this series, there was no significant difference in final results. However, Hospital charge in patients managed by ALP with shorter hospital stays was less than those managed by ALR. During follow-up periods (9 months to 6.5 years; on average 35.2 months), the patients were asymptomatic. ConclusionDysmotility of dilated duodenum, which is the hallmark of HJA, if not handled properly, would cause prolonged hospitalization due to feeding intolerance. Thus, traditional management of this kind of atresia aloneis not usually associated with acceptable results unless the limiting factors (inaccessible dilated D3 and D4 under the pancreas and superior mesenteric vessels) are overcome by DD after which the dilated segments of the duodenum and jejunum, now safely approachable, can be managed appropriately.

Outcomes of Biceps Tenodesis Variations With Concomitant Rotator Cuff Repair: A Multicenter Database Analysis.

Studies to date comparing biceps tenodesis methods in the setting of concomitant rotator cuff repair (RCR) have demonstrated relatively equivalent pain and functional outcomes. To compare biceps tenodesis constructs, locations, and techniques in patients who underwent RCR using a large multicenter database. Cohort study; Level of evidence, 3. A global outcome database was queried for patients with medium- and large-sized tears who underwent biceps tenodesis with RCR between 2015 and 2021. Patients ≥18 years of age with a minimum follow-up of 1 year were included. The American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, visual analog scale for pain, and Veterans RAND 12-Item Health Survey (VR-12) scores were compared at 1 and 2 years of follow-up based on construct (anchor, screw, or suture), location (subpectoral, suprapectoral, or top of groove), and technique (inlay or onlay). Nonparametric hypothesis testing was used to compare continuous outcomes at each time point. The proportion of patients achieving the minimal clinically important difference (MCID) at the 1- and 2-year follow-ups were compared between groups using chi-square tests. A total of 1903 unique shoulder entries were analyzed. Improvement in VR-12 Mental score favored anchor and suture fixations at 1 year of follow-up (P = .042) and the onlay tenodesis technique at 2 years of follow-up (P = .029). No additional tenodesis comparisons demonstrated statistical significance. The proportion of patients with improvement exceeding the MCID did not differ based on tenodesis methods for any outcome score assessed at the 1- or 2-year follow-up. Biceps tenodesis with concomitant RCR led to improved outcomes regardless of tenodesis fixation construct, location, or technique. A clear optimal tenodesis method with RCR remains to be determined. Surgeon preference and experience with various tenodesis methods as well as patient clinical presentation should continue to guide surgical decision-making.

A Cadaveric Study Examining the Accuracy of Wireless Hand-Held Guided Ultrasound Injections Versus Blind Injections in the Flexor Tendon Sheath

Hand-held ultrasound (HHUS) is gaining popularity among clinicians. Although its use for procedural guidance could have several advantages in hand surgery, other surgeons may wonder about its added benefits. This cadaveric study aimed to examine the hypothesis of increased accuracy of wireless HHUS-guided injections versus that of blind injections into the flexor sheath. Our series included 20 fresh cadaveric hands with 80 fingers randomly assigned to 2 groups. In group A, 10 hands were randomly assigned to receive a landmark injection and then received a blinded injection to the flexor tendon sheath (FTS). In group B, 10 hands were blinded in the same manner and received an ultrasound-guided injection with HHUS. Methylene blue was injected, and anatomic dissection was performed to evaluate the injection accuracy based on the dye's filling pattern in the FTS as stage I (no filling), stage II (<50% filling), and stage III (>50% filling). Statistical analysis was performed, and P <.05 indicated a significant difference. One finger was excluded because of severe Dupuytren contracture. In group A, 39 blind injections of the FTS were performed, with 82% (32/39) fingers achieving stage III filling. In group B, 40 ultrasound-guided FTS injections were performed, with 90% (36/40) of fingers achieving stage III filing. Our study did not reveal any superiority in accuracy when ultrasound guidance was used (P=.35). Hand-held ultrasound-guided FTS injections were not more accurate than blind injections performed by an experienced hand surgeon. These findings suggest that blind injections can be used as routine practice when performed by experienced operators to treat trigger finger. However, the use of HHUS may offer other advantages in hand surgery practice. Ultimately, choosing to perform HHUS-guided injection versus blind injection to treat trigger finger depends on the surgeon's experience and preference for a particular technique.

Surgical Management of Dupuytren Disease: A Systematic Review and Network Meta-analyses.

Dupuytren disease is a common fibroproliferative disease that affects the palmar fascia of the hands. Currently, there is limited consensus regarding the optimal therapy for this condition, with treatment decisions based largely on surgeon preference. Therefore, the aim of this study was to determine which treatments are the most effective for Dupuytren disease. A systematic review and network meta-analyses were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. Medline, EMBASE, and Web of Science were searched for randomized trials comparing treatments for Dupuytren disease in adults. Eligible treatments included open limited fasciectomy, collagenase injection, and percutaneous needle fasciotomy. Study selection, data extraction, and quality appraisal were performed in duplicate. The methodological quality was evaluated with the Cochrane risk-of-bias critical appraisal tool. Eleven randomized clinical trials were included in this study. At short-term (1-12 weeks) and long-term (2-5 years) time points, fasciectomy improved contracture release more than collagenase and needle fasciotomy as inferred by a lower total passive extension deficit. However, there was no difference between the groups regarding the best possible outcome at any time point. Fasciectomy was also superior in terms of recurrence and patient satisfaction compared with collagenase and needle fasciotomy, but only at later time points. There was no difference in skin damage-related and nerve damage-related complications following fasciectomy compared with other modalities. Risk of bias was generally moderate. Fasciectomy provides superior long-term advantages in terms of patient outcomes when compared with collagenase and needle fasciotomy. Larger trials with better blinding of outcome assessors are needed in the future.

Cemented total knee arthroplasty provides greater knee range of motion at 2years than cementless technique.

Optimal fixation method between cemented, cementless, and hybrid techniques for total knee arthroplasty (TKA) is still debated. The purpose of this study is to evaluate the clinical outcomes of patients undergoing cemented versus cementless TKA. We reviewed 168 patients who underwent a primary TKA at a single academic institution between January 2015 and June 2017. Patients were categorized into cemented (n = 80) or cementless (n = 88) groups. Only patients with greater than or equal to 2-year follow-up were included in the study. Multivariate regressions were performed to analyze the relationship between the surgical fixation technique and the clinical outcomes. There were no differences in demographics or baseline operative characteristics between the two groups. The cemented group had fewer manipulations under anesthesia (MUA) (4 vs. 15, p = 0.01), longer intraoperative tourniquet times (101.30 vs. 93.55min, p = 0.02), and increased knee range of motion (ROM) at final follow-up (111.48 vs. 103.75°, p = 0.02) compared to the cementless group. Both cemented and cementless component fixation are viable options for (TKA). This study found that patients who underwent a cemented TKA required fewer MUA's and had greater final ROM compared to patients undergoing cementless TKA. Additional research is required regarding cementless and cemented fixation. We believe that the choice of which fixation technique to use ultimately comes down to patient characteristics and surgeon preference.

Comparison of High Ligation Versus Low Ligation of the Inferior Mesenteric Artery (IMA) on Short-Term and Long-Term Outcomes in Sigmoid Colon and Rectal Cancer Surgery: A Meta-analysis.

This study was done to compare the perioperative outcomes and long-term outcomes between low ligation and high ligation of the inferior mesentric artery (IMA) in sigmoid colon and rectal cancer surgery.This study was conducted following the recommendations of the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). A literature search was performed in electronic databases including PubMed, CINAHIL, EMBASE, and Web of Science to identify studies published between January 1, 2015, and April 30, 2023.The outcomes assessed in this meta-analysis included postoperative complications (anastomotic leakage, surgical site infection, and postoperative ileus), intraoperative outcomes (duration of surgery in minutes, total intraoperative blood loss in milliliters, total lymph nodes harvested, and total number of metastatic lymph nodes), recovery outcomes (time to first flatus and length of hospital stay), and long-term outcomes (five-year mortality rate and disease-free survival rate).A total of 17 studies were included in this meta-analysis. Of these, six were randomized control trials (RCTs) and 11 were retrospective cohort studies. This meta-analysis suggests that lower ligation may be associated with a lower risk of anastomotic leakage compared to higher ligation in patients undergoing colon cancer surgery. However, there was no significant difference between the two techniques in terms of surgical site infection, postoperative ileus, total lymph nodes harvested, number of metastatic lymph nodes, duration of surgery, intraoperative blood loss, and length of hospital stay. Time to first flatus was significantly shorter in patients who underwent lower ligation. Additionally, there were no significant differences in the five-year mortality rate and disease-free survival rate between the two techniques. The results of this study indicate that both techniques are comparable in most aspects and suggest that the choice of technique should be based on individual patient factors and surgeon preference.

(543) Antibiotic Prophylaxis for Artificial Urinary Sphincter Surgery - Trends in AUA Best Practices Guideline Adherence

Abstract Introduction Infections involving an artificial urinary sphincter (AUS) can be devastating and costly. Antibiotic use during implantation is a mainstay in preserving the implant as well as reducing morbidity for patients. While antibiotic guidelines regarding urologic procedures have been published, it remains unclear how widespread these recommendations adoption or use is in practice especially with regards to AUS implantation. Objective Using the premier healthcare database (PHD), a large national database, we assessed trends in antibiotic prophylaxis for AUS in conjunction with the AUA Best Practice Guidelines on urologic procedures and antimicrobial prophylaxis. Methods The premier healthcare database (PHD) was queried from Q1 of year 2000 to Q1 of 2020. Encounters involving AUS insertion, removal, and/or associated complications were identified via ICD diagnosis, ICD procedure, and CPT codes. Premier charge codes were used to identify antibiotics administered during the insertion encounter. Antibiotics were grouped into categories based on antibiotic classification. Information pertaining to the day a particular item was billed was used to identify whether administration was ‘guidelines based’ or not. Antibiotic administration was considered guidelines based if they consisted of either Aminoglycosides and 1st/2nd generation Cephalosporin or Monobactam (Aztreonam) and 1st/2nd generation Cephalosporin. Removal or complications associated with AUS were identified on subsequent encounters and linked via the patients’ hospital identifier. Differences in removal and complication rates between patients with guidelines-based antibiotic administration at insertion were assessed via chi-squared tests. The association of guidelines-based administration with other categorical variables was also assessed via chi-squared tests. Differences between groups in continuous variables were assessed via Mann-Whitney U tests. Results A total of 9,976 patients having undergone AUS surgery were identified between 2000 and 2020, of which 1548 (16%) received AUA-adherent antibiotics. Six thousand six hundred and twenty six (66%) encounters were isolated since 2011. Mean age was 69.8 with 7485 (75%) Caucasian, 7158 (71%) utilizing Medicare. Mean length of hospital stay (LOS) was 0.4 days overall and 0.2 days compared to 0.5 (p&amp;lt;0.001) for patients receiving AUA-adherent to AUA non-adherent antibiotics. Patients receiving AUA-adherent antibiotic regimens (359 [23%]) had fewer complications than those receiving non-adherent regimens (2335 [28%]) (p&amp;lt;0.001) however no statistically significant reduction in encounters for removal or repair were noted (AUA-adherent 307 [20%]) to AUA-non-adherent 1826 [22%]) (p=0.11). No statistical significance was noted with regards to the decade of encounter, age, or race of the patient, or if the patient had received AUS teaching. Only 4.95% of patients received antibiotic therapy beyond the recommended 24-hour prophylactic recommendations. Conclusions Adherence to AUA-recommended, best practice antimicrobial guidlines, with regards to AUS implantation appears low. This is likely multifactorial and dependent on individual surgeon preferences, local antibiograms and resistance patterns as well as individual patient sensitivities and tolerances. Disclosure No

Open, Laparoscopic, and Robotic Approaches to Treat Colorectal Cancer: A Comprehensive Review of Literature.

Surgery is usually required to treat colorectal cancer (CRC). Medical technology has advanced, providing various approaches to tackle this disease. Different surgeries are available, such as laparoscopic surgery, single-incision laparoscopic surgery, natural orifice transluminal endoscopic surgery, and robotic surgery. Laparoscopic surgery has several benefits including reduced blood loss and shorter recovery time. It can also improve lung function and minimize complications. However, it requires more time to perform and has a higher risk of complications during the procedure. Robotic surgery provides a three-dimensional view of the surgical area allowing for greater precision in rectal surgeries and access to difficult-to-reach pelvic regions. This method utilizes robotics technology which reduces surgical time and speeds up recovery for patients. There are various surgical options available for treating CRC; however, laparoscopic surgery and robotic surgery offer unique advantages despite their own drawbacks. As technology continues to evolve, medical techniques will continue improving existing methods while providing new options resulting in better outcomes for patients. Compared to laparoscopy, robotic surgery has a lower rate of operative conversions and a shorter learning curve. However, it also has some drawbacks, such as a longer docking time, lack of tactile sensation, and higher cost. Therefore, the choice of surgical method should depend on patient characteristics, surgeon preference and expertise, and available resources. Currently, specialized centers offer robotic surgeries which are more expensive and take longer compared to open and laparoscopic approaches. Nonetheless, they are considered safe and feasible when compared to traditional surgery. Short-term outcomes for robotic surgeries are better, while long-term postoperative complicationrates remain similar. However, there is a need for additional well-defined randomized control trials conducted across multiple centers to validate the use of robotic surgery over open and laparoscopic approaches. Improving patient care and outcomes is the objective of this comprehensive literature overview on surgical approaches for CRC.

O157 Outcomes of concurrent hiatus hernia repair with different bariatric surgery procedures: a systematic review

Abstract Introduction Hiatus hernia (HH) are prevalent among patients with obesity. HH repair is often performed concurrently during bariatric surgery (BS), but a consensus on the safety and effectiveness of concurrent HH repair (HHR) and BS remains unclear. We, therefore, undertook a systematic review of the safety and effectiveness of concurrent HHR and BS through the measurement of multiple postoperative outcomes. Methods A comprehensive search discovered 17 studies relating to concurrent BS and HHR. BS procedures included laparoscopic Sleeve Gastrectomy (LSG), Roux-en-Y Gastric Bypass (LRYGB), and Adjustable Gastric Banding (LAGB). Extracted from these studies were pre- and post-operatives and measurements and outcomes. Results For LSG, 8 of 11 studies concluded concurrent procedures to be safe and effective with no increase in mortality. Reoperation rates however were increased with HHR, while GORD rates improved compared to LSG alone. For LRYGB, in all 5 studies, concurrent procedures were concluded to be safe and effective, with no increase in mortality, length of stay, readmission and reoperation rates. Higher complication rates were observed compared to LSG with HHR. Among LAGB studies, all 4 studies were concluded to be safe and effective with no adverse outcomes on mortality, length of stay and GORD rates. Reoperation rates from pouch dilatation and gastric prolapse were also observed to decrease. Conclusion Concurrent HHR with BS appears to be safe and effective. Assessment of BS warrants the consideration of concurrent HHR depending on specific patient case and the surgeon's preference.

Fast and versatile platform for pedicle screw insertion planning.

Computer-assisted surgical planning methods help to reduce the risks and costs in transpedicular fixation surgeries. However, most methods do not consider the speed and versatility of the planning as factors that improve its overall performance. In this work, we propose a method able to generate surgical plans in minimal time, within the required safety margins and accounting for the surgeon's personal preferences. The proposed planning module takes as input a CT image of the patient, initial-guess insertion trajectories provided by the surgeon and a reduced set of parameters, delivering optimal screw sizes and trajectories in a very reduced time frame. The planning results were validated with quantitative metrics and feedback from surgeons. The whole planning pipeline can be executed at an estimated time of less than 1min per vertebra. The surgeons remarked that the proposed trajectories remained in the safe area of the vertebra, and a Gertzbein-Robbins ranking of A or B was obtained for 95 % of them. The planning algorithm is safe and fast enough to perform in both pre-operative and intra-operative scenarios. Future steps will include the improvement of the preprocessing efficiency, as well as consideration of the spine's biomechanics and intervertebral rod constraints to improve the performance of the optimisation algorithm.

A network meta-analysis of the efficacy of arthrodesis with various fixation methods in the treatment of advanced ankle osteoarthritis

This study aimed to compare the efficacy of arthrodesis with various fixation methods in the treatment of advanced ankle osteoarthritis. Thirty-two patients with osteoarthritis of the ankle (mean age 59.91±6.16 years) took part in the study. The patients were divided into 2 groups - Ilizarov apparatus (21 patients) and screw fixation (11 patients). Each group was also divided into subgroups based on etiology - posttraumatic and nontraumatic. The AOFAS and VAS scales were compared in the preoperative and postoperative periods. It was found that screw fixation was more effective in the treatment of late stages of osteoarthritis (OA) of the ankle during the postoperative period. Comparison of the AOFAS and VAS scales showed no significant differences between the groups in the preoperative period (p = 0.838; p = 0.937). After 6 months, the results were better in the screw fixation group (p = 0.042; p = 0.047). Complications were observed for a third of the patients (10 patients). 6 patients had pain in the operated limb (4 patients in the Ilizarov apparatus group). Three patients in the Ilizarov apparatus group developed a superficial infection, and one developed a deep infection. Different etiology did not affect the postoperative efficacy of arthrodesis. The choice of the type of should be related to a clear protocol for the presence of complications. When choosing the type of fixation for arthrodesis, a patient's condition as well as a surgeon's preferences should be taken into account.