Early Discharge for Revision Total Knee and Hip Arthroplasty: Predictors of Success.

BACKGROUND: The rate of revision total joint arthroplasties is expected to increase drastically in the near future. Given the recent pandemic, there has been a general push toward early discharge. This study aimed to assess for predictors of early postoperative discharge after revision total knee arthroplasty (rTKA) and revision total hip arthroplasty (rTHA). METHODS: There were 77 rTKA and 129 rTHA collected between January 1, 2019 and December 31, 2021. Demographic data, comorbidities, a comorbidity index, the modified frailty index (mFI-5), and surgical history were collected. The Common Procedural Terminology codes for each case were assessed. Patients were grouped into 2 cohorts, early discharge (length of stay [LOS] <24 hours) and late discharge (LOS >24 hours). RESULTS: In the rTHA cohort, age >65 years, a history of cardiac or liver disease, an mFI-5 of >1, a comorbidity index of >2.7, a surgical time >122 minutes, and the need for a transfusion were predictors of prolonged LOS. Only the presence of a surgical time of >63 minutes or an mFI-5 >1 increased patient LOS in the rTKA cohort. In both rTHA and rTKA patients, periprosthetic joint infection resulted in a late discharge for all patients, mean 4.8 and 7.1 days, respectively. Dual component revision was performed in 70.5% of rTHA. Only 27.6% of rTKA were 2-component revisions or placements of an antibiotic spacer. CONCLUSIONS: Several patient and surgical factors preclude early discharge candidacy. For rTHA, an mFI-5 of >2/5, comorbidity index of >4, or a surgical time of >122 minutes is predictive of prolonged LOS. For rTKA, an mFI-5 of >2/5, Charlson Comorbidity Index of >5, or a surgical time of >63 minutes predicts prolonged LOS.

Comparison of cost, surgical time, and clinical results between arthroscopic transosseous rotator cuff repair with lateral cortical augmentation and arthroscopic transosseous equivalent suture bridge: A propensity score-matched analysis.

BACKGROUND: To reduce the healthcare burden, the clinical results of arthroscopic rotator cuff repair and the cost of the implants used have recently been focused upon. This study compared implant cost, surgical time, short-term clinical results, and cuff repair integrity 2 years postoperatively between arthroscopic transosseous rotator cuff repair using lateral cortical augmentation (TOA) and arthroscopic transosseous-equivalent suture bridge (TOE). METHODS: This study included 220 patients with rotator cuff repairs performed by a single surgeon between December 2013 and December 2018. Overall, 70 TOA and 68 TOE cases met the inclusion criteria. The same surgeon performed the procedures at two different hospitals, and the techniques differed between the facilities. A total of 42 TOA patients were matched with 42 TOE patients. The patients were matched using a propensity score analysis by gender, age, and cuff tear size. The minimum follow-up period was 2 years. Implant cost and surgical time were compared between the two methods. The range of motion, clinical outcomes, and visual analog scale were evaluated. Magnetic resonance imaging was performed to examine cuff repair integrity 2 years postoperatively. RESULTS: The follow-up rate was 81% (112/138 patients). Implant cost was significantly lower with TOA ($1,396 vs. $2,165; p < 0.001) than with TOE. The average surgical time in the TOA method was significantly shorter than that in the TOE method (82 vs. 109 min; p = 0.001). At a minimum 2-year follow-up, the mean active elevation, abduction, and clinical outcomes improved with both methods, although no improvements in external and internal rotations were observed with either method. There were no significant differences in the postoperative variables and retear rate (TOA, 12%; TOE, 19%; p = 0.548) between the two methods. CONCLUSIONS: TOA and TOE achieved comparable clinical results; however, TOA was more cost-effective and had a shorter surgical time than TOE. LEVEL OF EVIDENCE: Level Ⅲ, retrospective matched control study.

Intraoperative and early postoperative pain in cats that underwent ovariohysterectomy using a spay hook: a randomised, masked, experimental study.

BACKGROUND: This study aimed to compare the feasibility and practicality of the ovariohysterectomy (OHE) technique in cats with or without a spay hook with respect to the incision size, surgical time, surgical variables, and intra- and postoperative pain. Twenty-nine female cats underwent OHE using a spay hook (spay hook group [SHG], n = 15) or without using a spay hook (control group [CG], n = 14) to achieve the ovaries and cervix. Physiological parameters were monitored during the intraoperative period, and postoperative pain was assessed using a multidimensional composite and visual analogue pain scales. RESULTS: The SHG had a significantly shorter operative time than the CG. The variables in the intraoperative period showed no statistically significant difference between both groups, as well as the early postoperative pain. CONCLUSIONS: Less invasive OHE using a spay hook could potentially be a viable and feasible technique when performed by an inexperienced surgeon with appropriate training, especially in sterilisation campaigns, reducing the time to perform the procedure and increasing the number of animals spayed per time.

Comparison of suture-bridge and independent double-row techniques for medium to massive posterosuperior cuff tears: a two-year retrospective study.

BACKGROUND: Transosseous-equivalent suture-bridge (TOE-SB) and independent double-row (IDR) repair techniques were developed to treat rotator cuff tears. The study was designed to prove that both TOE-SB and IDR techniques provided comparable clinical results and retear rate for medium to massive posterosuperior rotator cuff tears, while the surgical time and number of suture anchor used were less in the IDR group. STUDY DESIGN: Level of evidence: level III, Retrospective comparative study. METHODS: Patients with medium to massive posterosuperior rotator cuff tears receiving arthroscopic TOE-SB and IDR between November 2016 to October 2019 were retrospectively enrolled. All patients were confirmed to have grade ≤ 2 fatty infiltration in the muscles of the torn tendons. Revision, concomitant subscapularis tear, acromiohumeral distance < 7 mm, glenohumeral osteoarthritis, partial repair, incomplete repair, partial thickness, or irreparable posterosuperior cuff tear were excluded. Surgical time, number of suture anchor used for the surgery, pre-operative, and post-operative clinical scores such as Constant-Murley score, subjective shoulder value (SSV), and visual analog scale (VAS) were compared. The retear rates between groups were evaluated by ultrasound. RESULTS: Thirty-five IDR and thirty-five TOE-SB repairs were enrolled. The IDR technique required much fewer anchors than TOE-SB did to complete the cuff repair. The mean operation time in IDR and TOE-SB group were 86(18.23), and 114(18.7) (min), respectively (P <  0.01). The mean number of anchors used to complete the cuff repair was 2(0.17) in IDR and 3(0.61) in TOE-SB (P <  0.01). The Constant-Murley score improved from 34.9 ± 6.6 to 80.6 ± 9.4 in the IDR group, and 37.4 ± 6 to 81.9 ± 4.6 in the TOE-SB group (both P <  0.001). SSV improved from 24.6 ± 9.6 to 79.3 ± 10.6 in the IDR, and 27.9 ± 9 to 82.9 ± 6.9 in the TOE-SB group (both P <  0.001). VAS improved from 7.9 ± 0.6 to 1.5 ± 0.7 in the IDR, and 8 ± 0.5 to 1.3 ± 0.6 in the TOE-SB group (both P <  0.001) at final follow-up. No significant difference was found between the retear rates (14.3% in the IDR vs. 17.1% in the TOE-SB, respectively) in the 2-year follow-up. CONCLUSIONS: Both IDR and TOE-SB group provided comparable clinical results and retear rates for medium to massive posterosuperior rotator cuff tears. The surgical time and number of anchors used were less in the IDR group than in the TOE-SB group.

NAVIO RATKA shows similar rates of hemoglobin-drop, adverse events, readmission and early revision vs conventional TKA: a single centre retrospective cohort study.

PURPOSE: Despite widespread adoption of NAVIO robotic-assisted total knee arthroplasty (NAVIO RATKA) in clinical practice, clinical outcome in terms of adverse events and complications remains unclear. The purpose of this study was to compare adverse events, length of stay, surgical time, hemoglobin drop, early readmission rate and revision rate between conventional TKA (CTKA) and NAVIO RATKA. METHODS: This single-centre retrospective cohort analysis compared 230 NAVIO RATKA patients to 489 CTKA patients with a minimal follow-up of 12 months. Baseline demographic and comorbidity parameters were collected, as well as length of stay, revision rate and reason for revision, early readmission rate (< 6w) and reason for readmission, post-operative hemoglobin levels, adverse events, surgical time and operating room time. Data were compared using Mann-Whitney U test for continuous data without normal distribution and ordinal data, categorical variables were compared using the Chi-square or Fisher exact test. RESULTS: There were no clinically relevant baseline demographic or comorbidity differences between groups. CTKA had shorter length of stay than NAVIO RATKA (5.0 days vs 5.4 days, p = 0.010) but trended towards a higher reoperation rate (4.1% vs 1.7%, p = .144, n.s). No differences were found in hemoglobin drop, readmission rate or overall incidence of adverse events, but CTKA showed more hematoma formation (1.6% vs 0%, p = .044) and higher incidence of periprosthetic joint infection (PJI) (1% vs 0%, p = n.s.), whilst NAVIO RATKA showed more periprosthetic fractures and persistent wound drainage (0.4% vs 2.2%, p = .038 and 0.6% vs 4.3%, p = .001, respectively). Surgical time remained significantly longer in NAVIO RATKA during all 230 cases (87 min vs 67.6 min) and showed a continuous downward trend. CONCLUSIONS: This study further validates the usage of NAVIO RATKA as a safe method to perform TKA, with comparable short term outcomes to CTKA in terms of early revisions and adverse events. Surgeons should be mindful of the differing adverse event profile in NAVIO RATKA and adjust their patient selection accordingly to ensure optimal outcomes. In addition, surgeons using NAVIO RATKA should expect a linear learning curve and a surgical time exceeding that of CTKA. LEVEL OF EVIDENCE: Level III (therapeutic retrospective cohort study).

Comparison between dexmedetomidine and propofol on outcomes after coronary artery bypass graft surgery: a retrospective study.

BACKGROUND: Dexmedetomidine (DEX) has a pharmacological profile that should allow rapid recovery and prevent undesirable outcomes such as pulmonary complications. METHODS: This large retrospective study compared the beneficial effects of perioperative infusion of DEX with propofol on the postoperative outcome after coronary artery bypass graft surgery. We reviewed patients' medical notes at Luoyang Central Hospital from 1st January 2012 to 31st December 2019. All continuous variables, if normally distributed, were presented as mean ± SD; Otherwise, the non-normally distributed data and categorical data were presented as median (25-75 IQR) or number (percentage). The Mann-Whitney U test and Chi-square test were used to evaluate the difference of variables between the DEX and propofol groups. Multivariate logistic regression analysis was performed on the main related and differential factors in the perioperative period. RESULTS: A total of 1388 patients were included in the study; of those, 557 patients received propofol infusion, and 831 patients received dexmedetomidine. DEX significantly reduced postoperative pulmonary complications compared with propofol, 7.82% vs 13.29%; P < 0.01, respectively. When compared with propofol, DEX significantly shortened the duration of mechanical lung ventilation, 18 (13,25) hours vs 21 (16,37) hours; P < 0.001, the length of stay in the intensive care unit, 51 (42,90) vs 59 (46,94.5) hours; P = 0.001 and hospital stay, 20 (17,24) vs 22 (17,28) days; P < 0.001, respectively. The incidences of postoperative wound dehiscence and infection were significantly reduced with DEX compared with propofol groups, 2.53% vs 6.64%; P < 0.001, respectively. Interestingly, patients receiving DEX had significantly shorter surgical time compared to propofol; 275 (240,310) vs 280 (250,320) minutes respectively (P = 0.005) and less estimated blood loss (P = 0.001). CONCLUSION: Perioperative infusion of dexmedetomidine improved the desirable outcomes in patients who had coronary artery bypass graft surgery compared with propofol.

Specific Factors Affecting Operating Room Efficiency: An Analysis of Case Time Estimates.

PURPOSE: Operating room (OR) efficiency has an impact on surgeon productivity and patient experience. Accuracy of case duration estimation is important to optimize OR efficiency. The purpose of this study was to identify factors associated with inaccurate case time estimates in outpatient hand surgery. A better understanding of these findings may help to improve OR efficiency and scheduling. METHODS: All outpatient hand surgical cases from 2018 to 2019 were reviewed. Poorly-estimated cases (i.e., poor scheduling accuracy) were defined as those cases where the actual operative time differed from the predicted time by >50% (either quicker by >50% or slower by >50% than the predicted time). The percentages of poorly-estimated cases were analyzed, categorized, and compared by surgeon, procedure type, and scheduled case length. RESULTS: A total of 6,620 cases were identified. Of 1,107 (16.7%) cases with poorly estimated case durations, 75.2% were underestimated. There was no difference in the likelihood of poor estimation related to start time. Well-estimated cases tended to have longer scheduled case duration, but shorter realized case duration and surgical time. Our systems analysis identified specific surgeons and procedures as predictable outliers. Cases scheduled for 15-30 minutes frequently were inaccurate, whereas cases scheduled for 30-45 and 106-120 minutes had accurate estimates. CONCLUSIONS: The accuracy of case time estimations in a standard outpatient hand surgery practice is highly variable. Nearly one-fifth of outpatient hand surgery case durations are poorly estimated, and inaccurate case time estimation can be predicted based on surgeon, procedure type, and case time. CLINICAL RELEVANCE: Maximizing OR efficiency should be a priority for surgeons and hospital systems. With multiple surgeries done per day, the efficiency of the OR has an impact on surgeon productivity and patient experience.

[Patient safety during endoprosthetic training : Does the training of surgeons in primary hip arthroplasty at certified endoprosthesis centres lead to increased complications?] / Patientensicherheit in der endoprothetischen Weiterbildung : Führt die Weiterbildung von Operateuren in der primären Hüftgelenkendoprothetik in zertifizierten Endoprothesenzentren zu vermehrten Komplikationen?

BACKGROUND: The aim of the study was to investigate whether the perioperative outcome and the operation-specific process variables in patients with total hip arthroplasty (THA) significantly deteriorate when the operation is performed by an inexperienced surgeon assisted by an experienced one in the context of a certified endoprosthesis center. MATERIAL AND METHODS: 1480 patients who received primary THA for primary coxarthrosis between 2013 and 2016 were included. The relevant data were retrospectively documented from the hospital information system, the discharge letter and the EndoCert form. The surgeons were divided according to their qualifications into experienced (senior surgeon, > 50 THA per year) and inexperienced surgeons (junior surgeon, < 50 THA per year). The collected data and measured variables were then compared based on this subdivision. RESULTS: Inexperienced surgeons showed a significant increase in the duration of the operation by 20.7 min (senior 62.6 ± 20.4 min; junior 83.3 ± 19.5 min; p ≤ 0.001), as well as the length of hospital stay by 0.25 days (senior 8.8 ± 0.9 days; junior 9.0 ± 0.9 days; p ≤ 0.001). The frequency of transfusions of red cell concentrates was significantly increased with inexperienced surgeons (senior 0.6 ± 1.1 items; junior 0.9 ± 1.4 items; p ≤ 0.001). In contrast, there was no difference in perioperative complications (p = 0.682) or in perioperative blood loss (senior 1.3 ± 0.5 l; junior 1.3 ± 0.5 l; p = 0.097). However, there was a positive correlation between the duration of the operation and blood loss (senior r = 0.183; junior r = 0.214; each p ≤ 0.01). CONCLUSION: The training of inexperienced surgeons at a certified endoprosthesis center does not lead to a reduction in patient safety or increased complications when inexperienced surgeons are assisted by experienced surgeons. Due to the extended operating time, however, there is an additional burden on the clinics in competition with non-training clinics, which is not mapped in the DRG system.

Effect of surgical start time on short- and long-term outcomes after minimally invasive esophagectomy: a propensity-score matching analysis.

There is growing focus on the relationship between surgical start time and postoperative outcomes. However, the extent to which the operation start time affects the surgical and oncological outcomes of patients undergoing esophagectomy has not previously been studied. The purpose of this retrospective study was to investigate the potential effect of surgical start time on the short- and long-term outcomes for patients who underwent thoracoscopic-laparoscopic McKeown esophagectomy. From September 2009 to June 2019, a total of 700 consecutive patients suffering from esophageal cancer underwent thoracoscopic-laparoscopic McKeown esophagectomy in the Department of Thoracic Surgery at Daping Hospital. Among these patients, 166 esophagectomies were performed on the same day and were classified as the first- or second-start group. Patients in the first-start group were more likely to be older than those in the second-start group: (64.73 vs. 61.28, P = 0.002). In addition, patients with diabetes mellitus were more likely to be first-start cases (8.4 vs. 1.2%). After propensity score matching (52 matched patients in first-start cases and 52 matched patients in second-start cases), these findings were no longer statistically significant. There was no difference in the incidence rate of peri- or postoperative adverse events between the first- and second-start groups. The disease-specific survival rates and disease-free survival rates were comparable between the two groups (P = 0.236 and 0.292, respectively). On the basis of the present results, a later start time does not negatively affect the short- or long-term outcomes of patients undergoing minimally invasive McKeown esophagectomy.

Difficult primary total knee arthroplasty requiring a varus-valgus constrained implant is at higher risk of periprosthetic infection.

PURPOSE: The goal of this study was to compare the risk of periprosthetic infection of a consecutive cohort of primary varus-valgus constrained (VVC) total knee arthroplasties (TKAs), with a matched 1:1 cohort of primary posterior-stabilized (PS) TKAs. METHODS: 74 primary VVC TKAs performed in 66 patients were identified and matched 1:1 with a cohort of 74 primary PS TKAs performed in 73 patients. At last follow up, patients were clinically evaluated using the Knee Society Score (KSS). Kaplan-Meier survival curves were generated to analyze survivorship using as endpoints revision for any reason, revision for periprosthetic infection and revision for mechanical failure after excluding periprosthetic infection. A multivariate logistic regression analysis was constructed to determine whether revision surgery for periprosthetic infection was influenced by patients' gender, age, surgical time and reasons for TKA (primary vs secondary osteoarthritis). RESULTS: Demographic data were not significantly different between the two groups as regard patients' age, gender, body mass index, Charlson Comorbidity Index, reasons for replacement, and length of follow-up. Surgical time was greater in the VVC group (95.7 ± 22.5 min vs 88.6 ± 17.1 min, respectively, p = 0.032). Postoperative KSS, range of motion and radiographic data did not differ significantly between the two groups. Overall revision rate and revision rate for mechanical failure after 5 years of follow-up was not statistically different between the two groups. Considering only the revision rate due to periprosthetic infection, the risk was higher in patients with primary VVC implants (p = 0.013). The surgical time was the only factor that significantly affected the risk of revision for periprosthetic infection (OR 1.0636, CI 95% 1.0209-1.1081, p = 0.0032), whereas patients' gender, age and reason for TKA had no influence. CONCLUSIONS: Patients and surgeons should be aware of the higher risk of periprosthetic knee infection using a VVC prosthesis. However, the present study supports the use of VVC implants in cases of difficult knee replacements, since comparable clinical outcomes and overall revision rate was found after at least 5 years of follow up. LEVEL OF EVIDENCE: Retrospective cohort study, Level III.

Computer navigation of the glenoid component in reverse total shoulder arthroplasty: a clinical trial to evaluate the learning curve.

BACKGROUND: Intraoperative computer navigation has been introduced recently to assist with placement of the glenoid component. The aim of this study was to evaluate the learning curve of a single surgeon performing computer navigation of glenoid implant placement in primary reverse total shoulder arthroplasty (RTSA). METHODS: Following training with the intraoperative computer navigation system, we conducted a prospective case-series study of the first 24 consecutive patients undergoing a primary RTSA with navigation performed by a single surgeon. Surgical times, complications, and accuracy of glenoid positioning compared with the preoperative plan were evaluated. Surgical times were compared with the preceding non-navigated series of 24 consecutive primary RTSA cases. Postoperative 3-dimensional computed tomography scans were performed to evaluate glenoid component version and inclination compared with the preoperative plan. RESULTS: The total surgical time was 77.3 minutes (standard deviation [SD], 11.8 minutes) in the navigated RTSA cohort and 78.5 minutes (SD, 18.1 minutes) in the non-navigated series. A significant downward trend in the total surgical time was observed in the navigated cohort (P = .038), which flattened after 8 cases. No learning curve was observed in deviation of glenoid version or inclination from the preoperative plan. The mean deviation of achieved version from planned version was 3° (SD, 2°), and the mean deviation of achieved inclination from planned inclination was 5° (SD, 3°). CONCLUSION: Findings from this study suggest that intraoperative computer navigation will not require substantially increased operating times compared with standard surgical techniques. With prior surgeon training, approximately 8 operative cases are required to achieve proficiency in intraoperative computer navigation of the glenoid component.

[PSI-technique for kinematic alignment]. / PSI ­ Technik des kinematischen Alignments.

BACKGROUND: Compared with the current gold standard of knee endoprosthetics, the concept of kinematic alignment is more responsive to the individual anatomy of the patient as it enables the three-dimensional restoration of individual axes, joint lines and capsule tension. One point of criticism is the lack of intraoperative control over individual bone resections with conventional instrumentation. However, with the help of CT-based individual 3D-printed cutting blocks, a precise preoperative plan can be transferred to the operating room. The aim of this article is to explain the operative technique of patient-specific instrumentation (PSI)-protected kinematic alignment. METHODS: The procedure is based on a preoperative 3D model of the bony anatomy of the patient, with the aid of which the planning of the operation, with the positioning and size of the implant, as well as the necessary bone resections, are carried out. With this information about anatomy and resection levels the individual cutting blocks are produced, aided by a 3D printer. Intraoperative control is achieved by measuring the resection by means of a gage and comparison with the digital 3D design. DISCUSSION: With the aid of the 3D-printed PSI cutting blocks the preoperative plan of kinematic alignment can be implemented in a precise manner. It is a simple tool and does not require any great expense. Compared with the conventional instrumentation, the operating time is shortened. However, because of the purely CT-based design, no information about the state of the soft tissue is obtained.

Comparison of proximal femoral nail (PFN) and dynamic hip screw (DHS) for the treatment of AO type A2 and A3 pertrochanteric fractures of femur.

OBJECTIVE: To compare the dynamic hip screw with proximal femoral nail for the treatment of Arbeitsgemeinschaft für Osteosynthesefragen type A2 and A3 per trochanteric fractures of femur. METHODS: The randomised controlled single-blind study was conducted at the Mayo Hospital, Lahore, Pakistan, from September 2015 to September 2017, and comprised patients aged 40-75 years with Arbeitsgemeinschaft für Osteosynthesefragen type A2 and A3 per trochanteric fracture. The patients randomised into two equal groups. In Group A, patients were treated by closed reduction and internal fixation with dynamic hip screw, while those in Group B were treated by closed reduction and internal fixation by proximal femoral nail. Follow-up was done at 2nd, 6th and 12th weeks, and at 6th, 9th and 12th month post-operatively. Variables evaluated were frequency of union, surgical time, approximate amount of blood loss and complications. The functional assessment was done by using Harris hip score. SPSS 20 was used for data analysis. RESULTS: Of the 68 patients, there were 34(50%) in each group. The mean age of patients in Group A was 60.88±12.49 years and in Group B it was 59.32±2.39 years. The mean surgery time in Group A was 58.71±7.84 minutes and in Group B 35.35±5.48 minutes (p<0.05). Mean blood loss was 273.82±30.0ml and 149.79±21.3ml in Group A and B respectively (p<0.05). The mean Harris hip score after 12 months in Groups A and B were 81.83±23.01 and 87.62±17.28 respectively. Infection was seen in 2(5.9%) patients in Group A and 1(2.9%) in Group B. CONCLUSION: Proximal femoral nail provided equivalent functional outcome compared to dynamic hip screw with lesser blood loss and surgical time.

Use of Historic Surgical Times to Predict Duration of Hysterectomy: Stratifying by Uterine Weight.

STUDY OBJECTIVE: To describe the accuracy of historic averages for estimating operating room (OR) time for hysterectomy among women with small and large uteri. DESIGN: A retrospective cohort study. SETTING: Data from women who underwent abdominal, vaginal, or laparoscopic hysterectomy between 2015 and 2017 at the University of North Carolina Hospitals were analyzed. Historic and actual OR times were compared using linear regression. Patient characteristics were also evaluated to determine whether they were associated with the accuracy of predicted OR times. PATIENTS: Nine hundred eighty-five adult women (≥18 years old) who underwent surgery for benign indications or for suspected but not biopsy-confirmed malignancy were included. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: Historic averages overestimated OR time by a median of 14 minutes (interquartile range [IQR] = -29 to 49 minutes). The OR time in women with small uteri (<250 g) was significantly more likely to be overestimated than women with large uteri (≥250 g) (median time = 21 minutes [IQR = -16 to 52 minutes] and 3 minutes [IQR = -38 to 44 minutes], respectively; p <. 001). In total laparoscopic hysterectomy and laparoscopy-assisted vaginal hysterectomy, women with uteri ≥250 g took significantly longer than hysterectomy for women with uteri <250 g (36 minutes longer [95% confidence interval, 24-50] and 95 minutes longer [95% confidence interval, 12-179], respectively; p < .001 and p = .03). CONCLUSION: Using historic averages overestimates OR time, and it is more pronounced in women with small uteri. However, there is a relatively large range of OR times, even among women with the same size uteri. This study highlights the importance of preoperative planning, and in cases in which endometriosis is expected, manually adding time to estimates is recommended.

Barbed Suture versus Conventional Suture for Vaginal Cuff Closure in Total Laparoscopic Hysterectomy: Randomized Controlled Clinical Trial.

STUDY OBJECTIVE: To determine the surgical time, suture time, presence of postoperative dyspareunia, and complications that occur after closing the vaginal cuff with a barbed suture compared with conventional suture. DESIGN: A randomized, controlled clinical trial (Canadian Task Force classification I). SETTING: Private gynecologic clinic in Medellin, Colombia. PATIENTS: One hundred fifty women who underwent total laparoscopic hysterectomy for benign pathology. INTERVENTIONS: The patients underwent total laparoscopic hysterectomy with intracorporeal closure of the vaginal cuff and were randomized to 2 groups, 1 using a barbed suture (V-Loc 90; Medtronic/Covidien, New Haven, CT) and 1 using polyglactin 910 (coated Vicryl suture; Ethicon/Johnson & Johnson, New Brunswick, NJ). MEASUREMENTS AND MAIN RESULTS: The total operative time, closing time of the vaginal vault, presence of complications in the cuff, and incidence of postoperative dyspareunia were recorded. The patients were evaluated at a postoperative office visit 2 weeks after the procedure and by telephone interview at 24 weeks. Seventy-five patients were included in the barbed suture group and 75 patients in the polyglactin 910 group. The average time to complete the suture of the vaginal cuff was 12.01 minutes (± 5.37 standard deviation) for the barbed suture group versus 13.49 minutes (± 6.48) in the polyglactin 910 group (95% confidence interval, -.44 to 3.4; p = .130). Blood loss was 31.56 ± 22.93 mL in the barbed suture group versus 30.82 ± 21.75 mL in the polyglactin 910 group (95% confidence interval, -7.95 to 6.47; p = .840). The frequency of postoperative events such as hematoma, cellulitis, cuff dehiscence, fever, emergency consultation, and hospitalization was not statistically significant between groups. No statistically significant difference was found regarding deep dyspareunia at 24 postoperative weeks. CONCLUSION: No differences were found in surgical time or frequency of adverse events when comparing patients after vaginal cuff closure with barbed suture versus polyglactin 910.

Tourniquet application does not affect the periprosthetic bone cement penetration in total knee arthroplasty.

PURPOSE: Poor scientific evidence exists on the issue of tourniquet application during total knee arthroplasty (TKA). It has been suggested that tourniquet application might improve interdigitation of the cement into the periprosthetic bones due to relatively dry surgical field. The hypothesis of the present study was that tourniquet use did not affect the periprosthetic bone cement penetration. METHODS: The single-centre, randomized, controlled trial included 86 patients undergoing primary TKA (Clinical-Trials.gov NCT02475603). All patients meeting the inclusion criteria were randomly assigned to the tourniquet (n = 43) or non-tourniquet (n = 43) group after obtaining a written informed consent. The cumulative bone cement penetration was radiologically measured in AP (seven zones) and lateral views (three zones) as defined by Knee Society Scoring System. Further parameters such as perioperative blood loss, soft tissue swelling, pain level/analgesic consumption, operative time, length of hospital stay (LOS) and complication rate were statistically compared between the groups. RESULTS: The cumulative bone cement penetration averaged 28.5 ± 1.7 mm in tourniquet versus 26.6 ± 1.6 mm in non-tourniquet groups (n.s.). The mean intraoperative blood loss was 250 ml higher in the non-tourniquet group (p = 0.0001). Patient-reported pre- to 6th-day post-operative reduction of the pain level was significantly higher in the non-tourniquet group (p = 0.003). The Morphine Equivalent Dose was higher in the Tourniquet group at discharge day (p = 0.02). Parameters such as total blood loss, soft tissue swelling, surgical time, LOS, and complication rates revealed similar results between the groups. CONCLUSIONS: Tourniquet application did not influence the bone cement penetration significantly. Even though the intraoperative blood loss was reduced, the total blood loss was not affected significantly by tourniquet use. There was a tendency of higher post-operative pain and opioid analgesic requirement in the tourniquet group. LEVEL OF EVIDENCE: I.

Surgeon Mean Operative Times in Total Knee Arthroplasty in a Variety of Settings in a Health System.

BACKGROUND: High-quality care is essential in total joint arthroplasty. Multiple initiatives such as centers of excellence, patient optimization, and alternative payment models have demonstrated improved outcomes and decreased cost. Many studies have shown that longer operative times (OTs) are associated with increased frequency of postoperative complications. These findings often come from large data sets and may not accurately represent the average OT of individual surgeons. The purpose of this study was to determine the hospital and patient-related factors that influence OT. METHODS: This retrospective study reviewed OT of 6003 total knee arthroplasty cases performed by 41 surgeons at 4 hospitals in a single health-care system. Mean OT was calculated for each surgeon. The effect of surgeon, hospital-, and patient-related factors on OT was assessed. RESULTS: Among the 41 surgeons, the mean OT was 105 ± 25 minutes. Two community hospitals had significantly faster OT compared with the tertiary care academic hospital. Surgeons' OT for morbidly obese patients was significantly longer compared with normal, overweight, and obese patients. Surgeon volume, surgeon experience, trainee presence, and American Society of Anesthesiologists status did not significantly affect surgical time. CONCLUSIONS: Operative time was influenced by hospital-related (tertiary, community) and patient-related (morbid obesity vs lower body mass index groups) factors. However, specific surgeon factors (surgical volume, experience), surgical team factors (presence or absence of trainee), and patient factors (American Society of Anesthesiologists status) did not significantly alter the OT. Additional studies of larger health systems are needed to examine additional patient, surgeon, and hospital factors which may influence the OT.

A randomized clinical trial of knotless barbed suture vs conventional suture for closure of the uterine incision at cesarean delivery.

BACKGROUND: Knotless barbed sutures are monofilament sutures with barbs cut into them. These sutures self-anchor, maintaining tissue approximation without the need for surgical knots. OBJECTIVE: The hypothesis of this study was that knotless barbed suture could be used on the myometrium to close the hysterotomy at cesarean delivery. The objective was to compare uterine closure time, need for additional sutures, and blood loss between this and a conventional suture. STUDY DESIGN: This was a prospective, unblinded, randomized controlled trial conducted at the Ziv Medical Center, Zefat, Israel. The primary outcome was the length of time needed to close the uterine incision, which was measured from the start of the first suture on the uterus until obtaining uterine hemostasis. To minimize provider bias, women were randomized by sealed envelopes that were opened in the operating room just prior to uterine closure with either a bidirectional knotless barbed suture or conventional suture. Secondary outcomes included the number of additional hemostatic sutures needed and blood loss during incision closure. RESULTS: Patients were enrolled from August 2016 until March 2017. One hundred two women were randomized. Fifty-one had uterine closure with knotless barbed suture and 51 with conventional suture. The groups were similar for demographics as well as number of previous cesarean deliveries. Uterine closure time using the knotless barbed suture was significantly shorter than the conventional suture by a mean of 1 minute 43 seconds (P < .001, 95% confidence interval, 67.69-138.47 seconds). Knotless barbed sutures were associated with a lower need for hemostatic sutures (median 0 vs 1, P < .001), and blood loss measured during incision closure was significantly lower (mean 221 mL vs 268 mL, P < .005). CONCLUSION: The use of a knotless barbed suture is a reasonable alternative to conventional sutures because it reduced the closure time of the uterine incision. There was also less need for additional hemostatic sutures and slightly reduced estimated blood loss.

Comparison of Customized Cutting Block and Conventional Cutting Instrument in Total Knee Arthroplasty: A Randomized Controlled Trial.

BACKGROUND: Customized cutting block (CCB) was designed to ensure the accurate alignment of knee prostheses during total knee arthroplasty. Given the paucity of CCB efficacy data, we compare CCB with conventional cutting guide using a randomized controlled trial. METHODS: One hundred eight osteoarthritic knee patients underwent total knee arthroplasty by one experienced surgeon were randomized to receive CCB (n = 54) or conventional cutting instrument (CCI) surgery (n = 54). The primary outcomes were limb alignment, prostheses position, and operative time. The secondary outcomes were hemodynamic alteration after surgery, functional outcomes (modified Western Ontario and McMaster University Osteoarthritis Index) and range of motion at 2 years after surgery. RESULTS: Mean hip-knee-ankle angle in the CCB group was 179.4° ± 1.8° vs 179.1° ± 2.4° in the CCI group, Δ = 0 (95% confidence interval [CI] -0.6 to 1.1, P = .55). Mean operative time was faster in the CCB arm: 93 ± 12 vs 104 ± 12 minutes, Δ = 11 (95% CI -16.7 to -7.2, P < .0001). There were no differences in hemodynamic parameters, mean blood loss (446 [CCB] vs 514 mL [CCI], Δ = -68 [95% CI -138 to 31 mL, P = .21]), postoperative hemoglobin changes, incidence of hypotension (systolic <90 mm Hg), oliguria, and rates of blood transfusion. Functional outcomes and range of motion were also similar. CONCLUSION: There was no improvement in alignment, hemodynamic changes, blood loss, and knee functional outcomes. CCB reduced surgical time by 11 minutes in our population. CCB cost-effectiveness should be further investigated.

A novel surgery technique: non-visual dissection for establishing the operating space during total endoscopic thyroidectomy.

BACKGROUND: Patients and surgeons are typically satisfied with the cosmetic results of total endoscopic thyroidectomy using the complete areola approach. However, the disadvantages of this approach include an excessive free flap and a longer operative time. METHODS: A retrospective analysis was conducted in 72 patients (64 women and 8 men) with a benign thyroid nodule who underwent non-unvisual dissection to establish the operating space for endoscopic surgery. RESULTS: The time needed to create the operating space in the chest was 6.43 ± 0.94 min. The time for the overall operating space was 15.35 ± 1.52 min. The overall surgical time was 96.54 ± 19.32 min. The flap area in the chest was 30.25 ± 3.42 cm2. CONCLUSIONS: Application of non-visual dissection shorten the time to create operating space and the overall surgical time, and markedly reduced the flap area. Our non-unvisual dissection technique for establishing the operating space is different from any previous techniques.