Surgeon Volume Research Articles

Trends and outcomes of outpatient total shoulder arthroplasty after its removal from CMS's inpatient-only list

In January 2021, the US Medicare program approved reimbursement of outpatient total shoulder arthroplasties (TSA), including anatomic and reverse TSAs. It remains unclear whether shifting TSAs from the inpatient to outpatient setting has affected clinical outcomes. Herein, we describe the rate of outpatient TSA growth and compare inpatient and outpatient TSA complications, readmissions, and mortality. Medicare fee-for-service claims for 2019-2022Q1 were analyzed to identify the trends in outpatient TSAs and to compare 90-day postoperative complications, all-cause hospital readmissions, and mortality between outpatients and inpatients. Outpatient cases were defined as those discharged on the same day of the surgery. To reduce the COVID-19 pandemic's impact and selection bias, we excluded 2020Q2-Q4 data and used propensity scores to match 2021-2022Q1 outpatients with inpatients from the same period (the primary analysis) and from 2019-2020Q1 (the secondary analysis), respectively. We performed both propensity score-matched and -weighted multivariate analyses to compare outcomes between the two groups. Covariates included sociodemographics, preoperative diagnosis, comorbid conditions, the Hierarchical Condition Category risk score, prior year hospital/skilled nursing home admissions, annual surgeon volume, and hospital characteristics. Nationally, the proportion of outpatient TSAs increased from 3% (619) in 2019Q1 to 22% (3456) in 2021Q1 and 38% (6778) in 2022Q1. A total of 55,166 cases were identified for the primary analysis (14,540 outpatients and 40,576 inpatients). Overall, glenohumeral osteoarthritis was the most common indication for surgery (70.8%), followed by rotator cuff pathology (14.6%). The unadjusted rates of complications (1.3 vs 2.4%, P<.001), readmissions (3.7 vs 6.1%, P<.001), and mortality (0.2 vs 0.4%, P=.024) were significantly lower among outpatient TSAs than inpatient TSAs. Using 1:1 nearest matching, 12,703 patient pairs were identified. Propensity score-matched multivariate analyses showed similar rates of postoperative complications, hospital readmissions, and mortality between outpatients and inpatients. Propensity score-weighted multivariate analyses resulted in similar conclusions. The secondary analysis showed a lower hospital readmission rate in outpatients (odds ratio: 0.8, P<.001). There has been accelerated growth in outpatient TSAs since 2019. Outpatient and inpatient TSAs have similar rates of postoperative complication, hospital readmission, and mortality.

A Survey of Microvascular Technique Preferences Among American Head Neck Society Members.

To identify practices in microvascular techniques in routine and challenging scenarios. Cross-sectional study. A national survey addressing practices related to microvascular free flap reconstruction was distributed to AHNS members between October and November 2021. The respondents encompassed 95 microvascular surgeons. Median years of practice was 6 (interquartile range, 2-13) and median flaps per year was 35 (22-50). Common practices in arterial anastomosis included limited cleaning of artery (84.2%), use of a double approximating clamp (64.2%), and use of interrupted suture (88.4%). Common practices in venous anastomosis included limited cleaning (89.5%), downsizing the coupler (53.7%), and coupling to two independent venous systems (47.4%). In arterial anastomosis, respondents felt that kinking (50.5%) and tension (24.2%) were the riskiest challenges. Kinking was handled by loose sutures or native tissue/dissolvable biomaterial to orient pedicle. Excess tension was handled by additional dissection. With regards to associated practices, most surgeons perform anastomosis after partial inset (52.6%), give aspirin immediately postoperatively (66.3%), reserve transfusion for hemodynamic instability (69.5%), and utilize intraoperative pressors when needed (72.6%). More senior surgeons reported placing more suture to address leaks (p = 0.004) and perform end to side anastomosis on larger vein in case of venous mismatch (p = 0.012). In cases of tension, higher volume surgeons perform more extensive dissection (p = 0.035) and end to side coupling (p = 0.029). This survey of AHNS members indicates patterns of microvascular techniques in routine and challenging scenarios. There exists a variation in approaches amongst surgeons based on volume and practice length. 5 Laryngoscope, 134:1265-1277, 2024.

SP9.14 “Happy to close?”: The relationship between surgical experience and incisional hernia rates following abdominal wall closure in colorectal surgery

Abstract Introduction There is an association between surgeon volume and outcomes in hernia surgery, yet little evidence regarding impact of the experience of the surgeon performing abdominal wall closure (AWC) on IH rate. Our aim was to assess the rates of IH at 1 year following surgery between Registrar and Consultant surgeons in patients undergoing elective colorectal surgery. Methods Patients undergoing elective surgery for colorectal cancer between 2014-2018 were identified through the Hughes Abdominal Repair Trial (HART). Grade of surgeon performing AWC was categorised into “Trainee” and “Consultant” and compared with IH detected at clinical examination at 1 year following surgery. Results 663 patients were included. 44% were closed by registrars (n=289). Groups were comparable in BMI, previous surgery and pre-operative IH. The rate of IH in patients closed by registrars was significantly higher than those closed by consultants (20% vs 12%, p&amp;lt;0.01). Patients who underwent AWC by a registrar were 88% more likely to develop IH at 1 year (OR 1.88, 95%CI 1.23-2.86, p&amp;lt;0.01). When comparing AWC methods, IH rates were significantly higher in the Hughes closure arm (20% vs 12%, p=0.03), but not high enough in the mass closure arm to reach significance (21% vs 13%, p=0.05). Conclusion Patients who undergo AWC by a registrar have an increased risk of developing IH compared to those closed by a consultant. This work suggests the importance of training during AWC. Further work is needed to determine the impact of supervised and un-supervised trainees on IH rates, but AWC should be treated as training time rather than coffee time.

The impact of surgeon volume on subscapularis repair and postoperative management following reverse shoulder arthroplasty

BackgroundReverse shoulder arthroplasty (RSA) recognition and acceptance is growing as patients report improved pain and function. Therefore, it is crucial to identify and modify factors that affect outcomes, some of the current aspects under discussion are subscapularis (SSc) management and postoperative rehabilitation (rehab) protocols. Our study seeks to evaluate the practices of American Shoulder and Elbow Surgeons members in managing the SSc during surgery and determining the best approach for postoperative rehab after RSA. MethodsAn eight-question survey was distributed to 1217 members of the American Shoulder and Elbow Surgeons, inquiring about SSc management and rehab practices following RSA. The survey included multiple-choice questions that evaluated characteristics of surgeon’s approach to rehab and perspectives of formal supervised outpatient therapy programs. The cohort was divided based on yearly RSA case volume and whether SSc is routinely repaired during RSA. ResultsMore than one third of surgeons (35.3%) reported ordering formal rehab due to patient expectations, but did not believe it was critical, and only 8.9% believed formal rehab to be critical in the recovery of patient strength. Almost two thirds (60.7%) of surgeons did not place a limitation on internal rotation. Of the 72.3% of surgeons that repaired the SSc, 49.7% restrict external rotation. When separating the cohort based on surgical volume, surgeons who performed more than 100 cases were significantly more likely to immobilize patients for more than 4 weeks postoperatively (P = .041). Surgeons who repaired the SSc were significantly more likely to immobilize patients for more than 4 weeks compared to surgeons who did not repair SSc (P < .001). ConclusionManagement of the SSc and surgeon case volume are critical factors in postoperative rehab after RSA. The majority of surgeons tend to repair the SSc, while only half of those that repair it immobilize it after surgery. Further studies that better evaluate the impact of postoperative immobilization on patient reported outcomes and satisfaction scores are needed in order to develop a more standardized approach and definitive guidelines.

ROSA VERSUS MAKO: COMPARING SURGICAL ACCURACY IN ROBOTIC TOTAL KNEE ARTHROPLASTY

AbstractIntroductionThere is increasing adoption of robotic surgical technology in Total Knee Arthroplasty - The ROSA® knee system can be used in either image-based mode (using pre-operative calibrated radiographs) or imageless modes (using intra-operative bony registration). The Mako knee system is an image-based system (using a pre-operative CT scan). This study aimed to compare surgical accuracy between the ROSA and Mako systems with specific reference to Joint Line Height, Patella Height and Posterior Condylar Offset.MethodologyThis was a retrospective review of a prospectively-maintained database of the initial 100 consecutive ROSA TKAs and the initial 50 consecutive Mako TKAs performed by two high volume surgeons. To determine the accuracy of component positioning, the immediate post-operative radiograph was reviewed and compared with the immediate pre-operative radiograph. Patella height was assessed using the Insall-Salvati ratio.ResultsThere was no significant difference between ROSA TKA and Mako TKA with regards to restoration of joint line height, ROSA mean 0.2mm versus Mako mean 0.3mm (p&lt;0.05), posterior condylar offset, ROSA mean 0.16mm versus Mako mean 0.3mm (p&lt;0.05), and patella height, ROSA mean 0.02 versus Mako mean 0.03 (p&lt;0.05)ConclusionThis study is the first study to compare the accuracy of the ROSA and MAKO knee systems in total knee arthroplasty. Both systems are highly accurate in restoring native posterior condylar offset, joint line height, and patella height in TKA with no significant difference demonstrated between the two robotic systems.

ROSA ROBOTIC ARM SYSTEM RELIABLY RESTORES JOINT LINE HEIGHT, PATELLA HEIGHT, AND POSTERIOR CONDYLAR OFFSET IN TOTAL KNEE ARTHROPLASTY

AbstractIntroductionThere is growing interest in the use of robotic Total Knee Arthroplasty (TKA) to improve accuracy of component positioning. This is the first study to investigate the radiological accuracy of implant component position using the ROSA® knee system with specific reference to Joint Line Height, Tibial Slope, Patella Height and Posterior Condylar Offset. As secondary aims we compared accuracy between image-based and imageless navigation, and between implant designs (Persona versus Vanguard TKA).MethodologyThis was a retrospective review of a prospectively-maintained database of the initial 100 consecutive TKAs performed by a high volume surgeon using the ROSA® knee system. To determine the accuracy of component positioning, the immediate post-operative radiograph was reviewed and compared with the immediate pre-operative radiograph with regards to Joint Line Height, Tibial Slope, Patella Height (using the Insall-Salvati ratio) and Posterior Condylar Offset.ResultsMean age of patients undergoing ROSA TKA was 70 years (range, 55 to 95 years). Mean difference in joint line height between pre and post-operative radiographs was 0.2mm (range −1.5 to +1.8mm, p&lt;0.05), posterior condylar offset mean change 0.16mm (range −1.4 to +1.3mm, p&lt;0.05), tibial slope mean change 0.1 degrees (p&lt;0.05) and patella height mean change 0.02 (range −0.1 to +0.1 p&lt;0.05). No significant differences were found between imageless and image-based groups, or between implant designs (Persona versus Vanguard).ConclusionThis study validates the use of the ROSA® knee system in accurately restoring Joint Line Height, Patella Height and Posterior Condylar Offset.

Trends in prevalence and implant types in the Nova Scotia Joint Database Registry between 2005 and 2021.

The aim of this study is to evaluate the change in incidence rate of shoulder arthroplasty, indications, and surgeon volume trends associated with these procedures between January 2003 and April 2021 in the province of Nova Scotia, Canada. A total of 1,545 patients between 2005 and 2021 were analyzed. Patients operated on between 2003 and 2004 were excluded due to a lack of electronic records. Overall, 84.1% of the surgeries (n = 1,299) were performed by two fellowship-trained upper limb surgeons, with the remainder performed by one of the 14 orthopaedic surgeons working in the province. Total shoulder arthroplasty (TSA) was the most frequent procedure (32.17%; n = 497), followed by stemmed hemiarthroplasty (SHA) (27.7%; n = 428). The most frequent indication for primary shoulder arthroplasty was degenerative osteoarthritis (58.1%; n = 882), followed by acute proximal humerus fracture in 15.11% (n = 245), and rotator cuff arthropathy in 14.18% (n = 220). The overall rate of revision was 7.7% (2.8% to 11.2%). The number of TSAs and reverse shoulder arthroplasties (RSAs) has been increasing since 2016. The amount of revision cases is proportional to the number of operations performed in the same year throughout the study period. The incidence of shoulder arthroplasty in the Maritime Provinces has increased over the last 16 years. Revision rates are similar the those found in other large database registries. Reverse shoulder arthroplasty prevalence has increased since 2016.

Shoulder &amp; Elbow

The August 2023 Shoulder &amp; Elbow Roundup360 looks at: Motor control or strengthening exercises for rotator cuff-related shoulder pain? A multi-arm randomized controlled trial; Does the choice of antibiotic prophylaxis influence reoperation rate in primary shoulder arthroplasty?; Common shoulder injuries in sport: grading the evidence; The use of medial support screw was associated with axillary nerve injury after plate fixation of proximal humeral fracture using a minimally invasive deltoid-splitting approach; MRI predicts outcomes of conservative treatment in patients with lateral epicondylitis; Association between surgeon volume and patient outcomes after elective shoulder arthroplasty; Arthroscopic decompression of calcific tendinitis without cuff repair; Functional outcome after nonoperative management of minimally displaced greater tuberosity fractures and predictors of poorer patient experience.

Use of intraoperative platelet-rich plasma during rotator cuff repair is correlated with increased patient-level charges across multiple categories.

As the efficacy of platelet-rich plasma (PRP) as an adjunct in rotator cuff repair (RCR) is debated, the decision to use PRP may be more heavily affected by its cost. We sought to quantify whether augmenting arthroscopic RCR with PRP injections at the time of surgery is correlated with increased patient-level charges. All outpatient records reported in Texas from 2010 to 2018 were obtained from the publicly available Texas Healthcare Information Collection database through the Texas Department of State Health Services. All records including a Current Procedural Terminology code for arthroscopic RCR were included. Of the 139,587 records identified within this group, 1662 also contained a Current Procedural Terminology code for intraoperative PRP injection. Patient-level charge data were compared between those who received and those who did not receive concomitant PRP injection during the same outpatient surgical encounter. Subgroup analyses were performed across surgical facilities and insurance types. Mann-Whitney U tests were used to compare charges between PRP and non-PRP cases. Linear regression was used to predict the change in billed charges according to standard charge categories. P values less than .05 were considered statistically significant. The total charges for arthroscopic RCR over the 8-year period were $4.66 billion, coming to $33,371±$22,118 per case. Cases that included PRP injection were found to have significantly greater overall charges than cases that did not ($54,452±$33,637 vs. $33,117±$21,818; P<.001). Linear regression indicated that concomitant PRP injections predicted an increase in combined total charges by $22,027 (95% confidence interval, $20,425-$23,628; P<.001). PRP utilization at the time of rotator cuff surgery is correlated with increased patient-level charges overall, which occur across all charge subcategories and persist across surgical facility, surgeon volume, and insurance type. Detailed cost analysis is recommended to explore this charge correlation, and future cost-benefit analyses of PRP use in RCR should explore costs beyond that solely associated with PRP preparation, as these may have previously been overlooked.

Strategies and factors to maximize cost-effectiveness of robotic surgery in benign gynecological disease.

Operating room procedures account for half of the gross hospital cost in the United States per annum. Hysterectomy is the eighth most common surgery nationally, with more than 300,000 cases every year. Since the introduction of robotic surgery in benign gynecology, concern has been raised regarding the increased cost without significant improvements in outcomes or practice. Surgeon volume, complication rates, length of hospital stay, and selected intraoperative instrumentation are all factors that have a direct effect on cost in robotic surgery. Cost is indirectly influenced by the OR team workflow, postoperative processes to expedite discharge, and converting surgery to the ambulatory setting. More research is needed to develop evidence-based practices for cost containment in robotic surgery.

Volume distribution of primary shoulder arthroplasty among low- and high-volume surgeons

BackgroundCare from high-volume surgeons has been shown to improve patient outcomes and reduce revision rates, complications, and hospital stays. According to prior research, most shoulder arthroplasties are performed by lower volume surgeons. However, this research is limited as it does not account for the recent increase in case numbers and projected growth of shoulder arthroplasty, and was focused only to states with urban populations. The purpose of this study is to identify and compare contemporary shoulder arthroplasty practice patterns and volume distributions in the state of Iowa. MethodsThe Iowa Hospital Association Databank was queried using International Classification of Diseases (ICD)-10 procedure codes for primary total shoulder arthroplasty. Surgeon and hospital volume were stratified according to procedures performed yearly as: low-volume <15 arthroplasties yearly, medium-volume 15-49, and high-volume ≥50 arthroplasties yearly. The proportion of surgeon and hospital volume, and number of procedures performed by each group were assessed. Distance traveled by patients to visit high-volume vs. low-volume surgeons and hospitals was compared. ResultsIn 2019, 1847 primary shoulder arthroplasties were performed in the state of Iowa by 144 surgeons at 49 institutions. Seventy four percent (106/144) of these surgeons were considered low-volume, 20% (29/144) medium-volume, and only 6% (9/144) were high-volume. However, 43% (793/1847) of shoulder arthroplasties were performed by high-volume surgeons, and 18% (333/1847) by low-volume surgeons. Eighteen percent (9/49) of hospitals where shoulder arthroplasties were performed qualified as high-volume institutions, whereas 45% (22/49) were low-volume. Compared to previous results, 65% (1194/1847) of procedures were performed at high-volume institutions and 6% (118/1847) at low-volume institutions. There was a significant difference in median distance traveled for patients to access high vs. low-volume surgeons (34 vs. 14 miles, P < .0001), and high-volume vs. low-volume hospitals (30 vs. 14.5, P < .0001). DiscussionIn the state of Iowa, while only a small portion of surgeons are considered “high-volume”, almost half of primary shoulder arthroplasties are performed by high-volume surgeons. These findings differ from the previous literature regarding volume distribution in shoulder arthroplasty. Furthermore, the results from this study demonstrate a shift from former documented trends which in the past had indicated that most shoulder arthroplasties were performed by low-volume surgeons. Data from this current study provides a glimpse into the evolution in practice patterns for shoulder arthroplasty. As practice patterns continue to evolve, further investigation may demonstrate improved patient outcomes in patients undergoing shoulder arthroplasty at higher volume hospitals with high-volume surgeons.

A comparison of revision rates for stemmed and stemless primary anatomic shoulder arthroplasty with all-polyethylene glenoid components: analysis from the Australian Orthopaedic Association National Joint Replacement Registry

We compared the rate of all-cause revision of 2 classes of primary anatomic shoulder arthroplasty, stemmed (stTSA) and stemless (slTSA), undertaken with cemented all-polyethylene glenoid components. A large national arthroplasty registry identified 2 cohort groups for comparison, stTSA and l undertaken for all diagnoses between January 1, 2011, and December 31, 2021. A subanalysis from January 1, 2017, allowed capturing of additional patient demographics including American Society of Anesthesiologists score, body mass index, and glenoid morphology. The cumulative percent revision (CPR) was determined using Kaplan-Meier estimates of survivorship and hazard ratios (HR) from Cox proportional hazard models adjusted for age and gender. Of the 7995 stTSA procedures, the CPR at 9 years was 5.6% (95% confidence interval [CI]: 5.0, 6.4), and for 3156 slTSA procedures, the CPR was 4.4% (95% CI: 3.6, 5.5). There was no significant difference in the rate of revision between the study groups (HR=0.76 [95% CI: 0.51, 1.14], P=.189, adjusted for age, gender, humeral head size, humeral fixation, bearing surface, glenoid design, and mean surgeon volume [MSV]). There was an increased rate of revision for stTSA and slTSA undertaken with humeral head sizes <44 mm (stTSA <44 mm vs. 44-50 mm, HR=1.56 [CI: 1.18, 2.08], P=.001; slTSA <44 mm vs. 44-50 mm, HR=2.08 [CI: 1.32, 3.33], P=.001). MSV as a continuous predictor was not a revision risk to stTSA vs. slTSA, but categorically, a low MSV (<10 stTSA+slTSA cases per annum) was associated with a higher revision rate for stTSA (10-20 cases/yr vs.<10 cases/yr, HR=0.72 [CI: 0.55, 0.95], P=.019) but was not in slTSA. Revision rates were increased for stTSA with non-crosslinked polyethylene (XLPE) glenoids vs. XPLE after 2 years (HR=2.20 [CI: 1.57, 3.08], P<.001) but did not significantly differ for slTSA. Metal/XPLE (humeral/glenoid) bearing surface of stTSA rate of revision was not different from each combination of slTSA bearing surface. Instability/dislocation was a revision risk for slTSA vs. stTSA (HR=1.93 [CI: 1.28, 2.91], P=.001), but from 2017, neither of American Society of Anesthesiologists score, body mass index, and glenoid morphology changed the rate of revision. Revision rates of stTSA and slTSA did not significantly differ and were associated with humeral head size but not patient characteristics. Surgeon inexperience of anatomic shoulder arthroplasty and non-XLPE glenoids were risk factors for stTSA revision but not slTSA. The metal/XLPE stTSA rate of revision was not found to differ significantly from slTSA regardless of polyethylene or humeral head bearing type. Revision for instability/dislocation was more common for slTSA.

Higher volume surgeons have lower 1-year postoperative cost after total shoulder arthroplasty

BackgroundThe relationship between total shoulder arthroplasty (TSA) volume and overall postoperative cost is unclear. The purpose of this study is to assess the impact of surgeon volume on total 1-year postoperative costs. MethodsAn observational cohort study was performed utilizing Marketscan databases. Patients undergoing inpatient TSAs between January 1st, 2017 and December 31st, 2019 were included. Patients with ICD-10 Diagnosis codes of trauma, fracture, or shoulder cancer were excluded. Surgeon volume was calculated as the maximum annual volume between 2017 and 2018. The primary outcome was total 1-year postoperative costs, including revision and nonoperative costs. Secondary outcomes were rates of revision and nonoperative procedures. ResultsThe analyzed study population consisted of 2216 patients from 1255 surgeons. Patients operated on by high-volume surgeons were more likely to be older, live in the Northeast and/or metropolitan area, and to have a reverse TSA performed. Total 1-year postoperative costs were lower for high-volume surgeons with an inverse relationship with surgeon volume (high: $1925 medium: $1715, low: $1193, P < .001). Physical therapy rates (high: 76.7%, medium: 82.0%, low: 86.6%, P < .001) and costs (high: $1223, medium: $1655, low: $1870, P < .001) were lowest for high-volume surgeons. ConclusionHigh-volume surgeons were associated with lower 1-year postoperative costs with revisions and physical therapy (PT) as the main driver of these costs. These improved outcomes may reflect surgeon skill and experience. Further research is necessary to establish standardized guidelines for postoperative PT regimen.

Higher Annual Total Hip Arthroplasty Volume Decreases the Risk of Intraoperative Periprosthetic Femur Fractures

BackgroundPeriprosthetic femur fracture (PFF) is a complication of total hip arthroplasty (THA). These occur intraoperatively or postoperatively, and documented risk factors of PFFs include women, age greater than 65 years, cementless stems, and inflammatory arthropathies. The aim of this retrospective cohort study was to assess the relationship of years of surgical experience and surgeon annual THA volume on intraoperative and postoperative PFFs. MethodsData were collected from a database query, and PFFs were identified as either intraoperative or postoperative. Intraoperative and postoperative PFFs were both compared to a control group of non-PFF patients. Years of surgical experience at the time of surgery and annual THA volume for the primary surgeon were calculated for all cases. Logistic regression analyses were used to calculate odds ratios for each of the surgeon variables when adjusted for patient demographics. ResultsThirty-seven intraoperative and 108 postoperative PFFs were identified and compared to 7,629 controls. From regression analyses, high-volume surgeons (≥50 THA/year) had lower odds of intraoperative PFF (adjusted odds ratio (aOR) = 0.40, P = .020) but not postoperative PFF (aOR = 1.02, P = .921). Surgeon experience (≥15 years since board certification at the time of surgery), was not significantly related to either PFF outcomes. For patient factors, age ≥65 years (aOR = 2.30, P < .001) and women (aOR = 2.69, P < .001) were both significant predictors of postoperative PFFs only. ConclusionSurgeons who performed 50 or more THAs per year had significantly fewer intraoperative PFFs than surgeons who did less than 50 THAs per year. Surgeon experience was not significantly related to PFFs.

The Effect of Surgeon and Hospital Volume on Total Knee Arthroplasty Patient-reported Outcome Measures: An American Joint Replacement Registry Study.

The lower morbidity and mortality rate associated with increased surgeon and hospital volume may also correlate with improved patient-reported outcome measures. The goal of this study was to determine the relationship between surgeon and hospital volume and patient-reported outcome measures after total knee arthroplasty (TKA) using American Joint Replacement Registry data. Using American Joint Replacement Registry data from 2012 to 2020, 8,193 primary, elective TKAs with both preoperative and 1-year postoperative The Knee Injury and Osteoarthritis Outcome Score, Joint Replacement (KOOS-JR) scores were analyzed. This study was powered to detect the minimally clinical important difference (MCID). The main exposure variables were median annual surgeon and hospital volume. Tertiles were formed based on the median annual number of TKAs performed: low-volume surgeons (1 to 52), medium-volume (53 to 114), and high-volume (≥115); low-volume hospitals (1 to 283), medium-volume (284 to 602), and high-volume (≥603). The mean preoperative and 1-year postoperative KOOS-JR were compared. Multivariable logistic regression models were used to determine the effect of surgeon and hospital volume and demographics on achieving the MCID for KOOS-JR. The mean preoperative and 1-year postoperative KOOS-JR score for low-volume surgeons was 47.78 ± 13.50 and 77.75 ± 16.65, respectively, and 47.32 ± 13.73 and 76.86 ± 16.38 for low-volume hospitals. The mean preoperative and 1-year postoperative KOOS-JR score for medium-volume surgeons was 47.20 ± 13.46 and 76.70 ± 16.98, and 48.93 ± 12.50 and 77.15 ± 16.36 for medium-volume hospitals. The mean preoperative and 1-year postoperative KOOS-JR scores for high-volume surgeons were 49.08 ± 13.04 and 78.23 ± 16.72, and 48.11 ± 13.47 and 78.23 ± 17.22 for high-volume hospitals. No notable difference was observed in reaching MCID for KOOS-JR after adjustment for potential confounders. An increased number of TKA cases performed by a given surgeon or at a given hospital did not have an effect on achieving MCID for KOOS-JR outcomes.

Surgeon volumes: preserving appropriate surgical outcomes in higher-risk patient populations undergoing abdominal wall reconstruction.

It is increasingly recognized that complex abdominal wall reconstruction (cAWR) necessitates specialized training. No studies have been conducted to assess whether a volume-outcomes relationship is present in cAWR. We sought to determine if outcomes for patients undergoing cAWR varied based on surgeon volume among participants in the Abdominal Core Health Quality Collaborative (ACHQC). All patients with ventral hernias undergoing elective cAWR with component separation (lateral component release) were selected from ACHQC database. Surgeons were ranked based on annual number of cAWR procedures performed and then grouped in tertiles. Patient characteristics, hernia risk factors, operative details, and 30-days outcomes were evaluated. A total of 9206 patients were identified, of which 310 (3.4%), 723 (7.9%) and 8173 (88.7%) cAWRs were performed by low (105 surgeons), medium (49) and high-volume (66) surgeons, respectively. Patients operated upon by high-volume surgeons tended to have more comorbidities and higher ASA class (72.5% of class ≥ III, vs 53.5%). Hernia characteristics demonstrated that high-volume surgeons more commonly operated on patients presenting with recurrent hernias (50.2% vs 42%), wider hernias (13.5cm vs 10.5cm), associated ostomies (13% vs 3.6%), and prior of surgical site infections (32% vs 26%, P = 0.035). High-volume surgeons more commonly performed posterior component separation procedures (92% vs 84%), utilized permanent mesh (92% vs 88%), and placed mesh in sublay position. In spite of operating on more advanced hernias, high-volume surgeons achieved comparable rates (all P > 0.4) of 30-day surgical site infections (SSI: 6.9% vs 7.1%) and surgical site occurrences requiring procedural intervention (SSO-PI: 8.9% vs 10%). High-volume surgeons maintain comparable outcomes following cAWR despite performing operations on patients with more comorbidities and advanced hernia disease. These findings should be integrated into the debates related to regionalizing abdominal wall reconstruction procedures among high-volume surgeons.

Guideline Compliant Minimum Asymptomatic Carotid Endarterectomy Surgeon and Hospital Volume Cutoffs

There is a known association between volume and outcomes after carotid endarterectomy (CEA). A recent analysis suggested rates of stroke and death do not significantly reduce after a surgeon volume cutoff of 20 CEAs per year. However, these results would severely limit access. The objective here is to identify a lower optimal cutpoint for surgeon and hospital volume for asymptomatic CEA. We evaluated asymptomatic CEA patients using The New York Statewide Planning and Research Cooperative System database from 2000-2014. The relationship of 3-year averaged volumes for surgeons and hospitals to 30-day stroke were assessed using multiple logistic regression and included both hospital and surgeon volume in all analyses. Optimized cutpoints were the lowest significant volume cutoff that minimized the adjusted odds ratio of stroke. We studied 32,549 CEAs performed by 271 surgeons in 136 centers by vascular surgeons. The median surgeon volume was 26.3(IQR:12.3-51.7) and the median hospital volume was 67(IQR:36.3-119.3). The surgeon volume cutpoint was 3 and the hospital volume cutpoint was 6 cases per year. There were 756(2.3%) procedures performed by surgeons with a volume <3 and 560 (1.7%) procedures performed by hospitals with a volume <6. Perioperative stroke and death rates were 2.0% (95%CI:1.8-2.1) and 3.8% (95%CI:2.6-5.5) for an average yearly surgeon volume ≥3 and <3 (p=0.070), respectively. The combined Stroke and death rate was 2.0% (95%CI:1.8-2.1) and 4.8% (95%CI:3.2-7.0) for an average yearly center volume ≥6 and <6 (p=0.007), respectively. A combined surgeon and hospital volume variable also predicted outcomes and low volume procedures did not meet previously proposed AHA and SVS quality measures. These data demonstrate an improvement in outcomes at a lower volume threshold than previously reported. These modest cutoff values should be used for asymptomatic CEA volume guideline formation and for future studies, after accounting for the impact of other important factors that may be driving volume-outcomes relationships in asymptomatic CEA.

Lateral neck dissection surgeon volume and complications in head and neck endocrine malignancy.

Increased surgeon volume is associated with decreased complications for many surgeries, including thyroidectomy. We sought to use two national databases to assess for associations between surgeon volume and complications in patients undergoing lateral neck dissection for thyroid or parathyroid malignancy. Lateral neck dissections for thyroid and parathyroid cancer from the Nationwide Inpatient Sample and State Inpatient Database were analyzed. The primary outcome was any inpatient complication common to thyroidectomy, parathyroidectomy, or lateral neck dissection. The principle independent variable was surgeon volume. Multivariable analysis was then performed on this retrospective cohort study. The 1,094 Nationwide Inpatient Sample discharges had a 28% (305/1,094) complication rate. After adjustment, surgeons with volumes between 3-34 neck dissections/year demonstrated a surgeon volume-complication rate association [adjusted odds ratio: 1.03; 95% confidence interval (CI): 1.01-1.05]. The 1,235 State inpatient Database discharges had a 21% (258/1,235) overall complication rate, and no association between surgeon volume and complication rates (P=0.25). This retrospective review of 2,329 discharges for patients undergoing lateral neck dissection for thyroid or parathyroidectomy demonstrated somewhat conflicting results. The Nationwide Inpatient Sample demonstrated increasing complication rates for increasing surgeon volume among intermediate volume surgeons, while the State Inpatient Database demonstrated no surgeon volume-complication association. Given these disparate results, and further limitations with these databases, conclusions regarding surgical volume and clinical decision making based on these data should be assessed cautiously.

Surgical rescue strategies and techniques for gastrointestinal fistulas

Abstract A gastrointestinal fistula is a severe medical condition that may lead to sepsis or septic shock. It requires immediate response and valid treatment to prevent subsequent deterioration. Surgical rescues are effective measures to cope with aforementioned situations, but there remain challenges in successful implementation. Institutional factors, including constrained hospital volume, technological gap, and limited competence of surgeons and nurses, could lead to surgical failure to rescue (FTR), while high-risk patient characteristics such as aging, diabetes mellitus, and chronic organ dysfunction have a bearing on the outcome as well. Surgical rescue strategies encompass damage control surgery and resuscitation. Based on disease severity, sequential damage control measures involving vessel catheter removal, abdominal drainage tube replacement, trocar-assisted percutaneous abscess drainage, laparoscopic drainage, and open abdomen therapy should be applied accordingly.

Open and endovascular repair of thoracoabdominal aortic aneurysm-a narrative review.

Thoracoabdominal aortic aneurysms (TAAAs) are associated with a high rate of morbidity and mortality when left untreated, yet their repair has been associated considerable risk as well. We aim to present a review of the epidemiology, risk factors, pathophysiology, natural history, management strategies, and current literature on open and endovascular repair of thoracoabdominal aortic aneurysms. A narrative review using current search of the most recent literature on this topic. Indication for surgical repair includes symptomatic aneurysms and those at a size or growth threshold. Open repair is the gold standard for surgical management of TAAA and remains so, however, endovascular repair has an increasingly broad applicability, and technology has correspondingly improved in the two decades since its introduction to clinical practice. Reported contemporary operative mortality has ranged from less than 5% to over 20%. The primary adverse complication of open and endovascular repair is ischemic injury, including renal injury, with reported incidence ranging from 2.8-12.5% in contemporary series, and spinal cord injury, with reported incidence ranging from 2.5% to 7.3% in contemporary series. Cerebrospinal fluid drainage has been shown to be the best-proven mechanism to date to prevent spinal cord injury in both open and endovascular repair. Endovascular repair is associated with a higher reintervention rate than open repair. Surgeon and center volume and expertise are related to clinical outcomes and should be taken into consideration when deciding on surgical repair.