Surgeon's Prediction Research Articles

Quantifying Surgeon Intuition Using a Judgment Analysis Model: Surgeon Accuracy of Predicting Patient-Reported Outcomes in Patients Undergoing Hip Arthroscopy for Femoroacetabular Impingement Is Moderate at Best

To quantify surgeon intuition, determine whether a surgeon's prediction of outcomes after hip arthroscopy correlates with actual patient-reported outcomes (PRO), and identify differences in clinical judgment between expert and novice examiners. This prospective, longitudinal study was conducted at an academic medical center on adults undergoing primary hip arthroscopy for treatment of femoroacetabular impingement. A Surgeon Intuition and Prediction (SIP) score was completed preoperatively by an attending surgeon (expert) and physician assistant (novice). Baseline and postoperative outcome measures included legacy hip scores (e.g., Modified Harris Hip score) and Patient-Reported Outcomes Information System tools. Mean differences were assessed using t-tests. Generalized estimating equations assessed longitudinal changes. Pearson correlation coefficients (r) evaluated associations between SIP score and PRO scores. Data from 98 patients (mean age 36 years, 67% female) with complete data sets at 12-month follow-up were analyzed. Weak-to-moderate strength correlations were seen between SIP score and PRO scores (r= 0.36 to r= 0.53) for pain, activity and physical function. Significant improvements were seen in all primary outcome measures at 6 and 12 months postoperatively when compared to baseline scores (P < .05), with about 50% to 80% of patients achieving the minimum clinically important difference and patient acceptable symptomatic state thresholds postoperatively. An experienced, high-volume hip arthroscopist had only weak-to-moderate ability to intuitively predict PRO. Surgical intuition and judgment were not superior in an expert examiner compared to a novice. Level III, retrospective comparative prognostic trial.

What Is the Value of Component Loosening Assessment of a Preoperatively Obtained Bone Scan Prior to Revision Total Knee Arthroplasty?

BackgroundBone scintigraphy (BS) is frequently ordered to investigate cause of failure following total knee arthroplasty (TKA). Its correlation of component loosening with intraoperative findings (IFs) at the time of revision TKA (rTKA) has not been well studied. This study investigated correlations between the preoperatively obtained radiologist report (RR) of BS, preoperatively documented surgeon prediction (SP) of component loosening, and operative reports documenting IFs. MethodsOur institutional database was retrospectively reviewed for all rTKA done after BS and revealed 96 eligible cases. The RR and SP cohorts were subdivided into all potential combinations of component loosening and were then compared with each other as well as IF. In addition to calculating the percentage correct of RR and SP compared with IF, the levels of agreement between RR and SP were compared using the kappa statistic. ResultsOf the 96 cases, the RR correctly correlated with IF in 35 cases (37%), whereas the SP was correct in 66 cases (69%), indicating the preoperative interpretation of the surgeon regarding component loosening at rTKA was correct more frequently (P < .001). The kappa statistic between RR and IF was only 0.23 (95% confidence interval [CI] = 0.15-0.32), indicating minimal agreement. The kappa statistic between SP and IF was 0.57 (95% = CI 0.46-0.68), indicating weak agreement. Furthermore, the kappa statistic between RR and SP was 0.36 (95% CI = 0.27-0.45), also indicating minimal agreement. ConclusionsIn rTKA, there is weak agreement regarding component loosening between a radiologist’s opinion of a preoperatively obtained bone scan and the surgeon’s preoperative interpretation of clinical and radiographic data. While neither reliably accurately predicts what is found at the time of rTKA, the surgeon’s preoperative interpretation is more closely correlated with actual IFs of component loosening.

Surgical Intuition.

Surgical Intuition.

Use of Historical Surgical Times to Predict Duration of Primary Total Knee Arthroplasty

BackgroundPrimary total knee arthroplasty (TKA) is one of the most commonly performed procedures at US hospitals. Surgeons are typically asked to estimate surgical control time (SCT) needed for the procedure. Here, we compare the performance of a surgeon's prediction against a potentially more accurate method of using historical averages over the last 3, 5, 10, and 20 cases. MethodsData were collected on all scheduled primary TKAs done at one institution from October 2008 to September 2014. For each case, actual SCT (aSCT) and predicted SCT were obtained. Historical SCTs were calculated based on the mean of the last 3, 5, 10, and 20 aSCTs of the same surgeon. Estimation biases were calculated based on the difference between aSCT and predicted SCT or between aSCT and historical estimates. Values were compared using Kruskal-Wallis analysis of variance and Steel-Dwass pairwise comparisons. ResultsA total of 2539 primary TKAs were evaluated across 9 surgeons. Surgeons overestimated SCT by an average of 18.1 minutes. Using 3-20 cases in the historical average reduced mean estimation bias to a range of −0.1 to −0.3 minutes (P < .001). None of the historical estimations were significantly different from each other, demonstrating a lack of improvement with additional cases (P < .001). ConclusionHistorical averages of procedure times appear to be a promising method of estimating surgical time for primary TKAs. Here, we show that even a small number of cases (eg, 3) can reduce estimation biases compared to solely using surgeons' estimates alone.

Visual phenomena perceived during pars plana vitrectomy under peribulbar block and monitored anaesthesia care

AimTo investigate patients’ sensory phenomena, especially instrument visualisation, and their emotional reactions during pars plana vitrectomy (PPV) under monitored anaesthesia care (MAC).MethodsOne hundred adults who underwent PPV under MAC plus...

Predicting the Unpredictable

: Routine predictions made by surgeons or historical mean durations have only limited capacity to predict operating room (OR) time. The authors aimed to devise a prediction model using the surgeon's estimate and characteristics of the surgical team, the operation, and the patient. : Seventeen thousand four hundred twelve consecutive, elective operations from the general surgical department in an academic hospital were analyzed. The outcome was OR time, and the potential predictive factors were surgeon's estimate, number of planned procedures, number and experience of surgeons and anesthesiologists, patient's age and sex, number of previous hospital admissions, body mass index, and eight cardiovascular risk factors. Linear mixed modeling on the logarithm of the total OR time was performed. : Characteristics of the operation and the team had the largest predictive performance, whereas patient characteristics had a modest but distinct effect on OR time: operations were shorter for patients older than 60 yr, and higher body mass index was associated with longer OR times. The surgeon's estimate had an independent and substantial contribution to the prediction, and the final model explained 27% of the residual variation in log (OR time). Using the prediction model instead of the surgeon's prediction based on historical averages would reduce shorter-than-predicted and longer-than-predicted OR time by 2.8 and 6.6 min per case (a relative reduction of 12 and 25%, respectively), assessed on independent validation data. : Detailed information on the operative session, the team, and the patient substantially improves the prediction of OR times, but the surgeon's estimate remains important. The prediction model may be used in OR scheduling.

Comparison of Flow Cytometry With the Surgeon Regarding Ability to Predict the Ultimate Success of Surgery for Proliferative Vitreoretinopathy

To analyze vitreous specimens obtained from human eyes with proliferative vitreoretinopathy (PVR) by use of flow cytometery (FC) to compare the capacity of FC with that of the surgeon's in predicting the ultimate outcome after PVR surgery. Thirty-one vitreous aspirates were obtained at vitrectomy or from postoperative fluid-gas exchanges for complicated retinal detachment due to PVR. Samples were analyzed by FC for the concentration of total and proliferating cells. These measurements were compared with the surgeon's preoperative prognosis (good, poor, or indeterminate) for the ultimate result. At 12 weeks, the eyes were evaluated for clinical outcome. An unsuccessful outcome was one in which the retina was attached with macular pucker or hypotony or was anatomically detached. Anatomic attachment of the retina anterior and posterior to the scleral buckle without these findings was considered a successful outcome. Flow cytometry was capable of quantifying the concentration of total and proliferating cells in eyes with PVR. Eyes destined for an ultimately successful outcome demonstrated fewer total and proliferating cells than did eyes destined for an unsuccessful outcome. No differences were observed between eyes destined for development of macular pucker and those destined for anatomic redetachment. The surgeon was able to accurately predict a good or a poor outcome in 64.5% of the cases, with a sensitivity of 92% and a specificity of 89%. Using the total number of recovered cells, FC was able to correctly predict a good or a bad outcome with a 77% accuracy, whereas the surgeon was able to do so with a 65% accuracy. Combining the surgeon's prediction with the result of FC increased the diagnostic power of the prediction to 87%. The diagnostic power of FC was similar to that of the surgeon's in predicting ultimate outcome, but the two techniques probably evaluate different features of the disease process. The combination of the two techniques was the most powerful approach to the prediction of ultimate outcome after PVR surgery.

The assessment of skin viability using fluorescein angiography prior to amputation.

Fluorescein angiography was used for the preoperative assessment of skin viability and the determination of the level of amputation in patients with peripheral vascular disease. In twenty-two patients requiring twenty-seven lower-extremity amputations (including five revisions), a retrospective comparison was made between the surgeon's choice of amputation level based on clinical criteria and that based on the fluorescein angiogram. As was evident by the failure of the amputation to heal, the surgeon's prediction was too distal in nine (33 per cent) of twenty-seven amputations and revisions. The assessor of fluorescein angiograms predicted five of these nine failures; therefore, the failure rate could have been reduced to four (15 per cent) of twenty-seven amputations. The amputation level predicted on the basis of the fluorescein angiogram was unnecessarily high in three lower limbs (11 per cent). These three amputations healed at the level chosen by the surgeon, but did so by prolonged secondary healing. Fluorescein angiography is a simple, safe, and useful preoperative bedside technique for the assessment of skin viability and the determination of amputation level in patients with peripheral vascular disease.

Some clinical notes on patients with mitral valvular disease who have had mitral valvuloplasty. Part II

Some clinical notes on patients with mitral valvular disease who have had mitral valvuloplasty. Part II