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Cintean R, Degenhart C, Pankratz C, Gebhard F, Schütze K. An Analysis of 1000 Patients With the "Big 5" Orthopaedic Surgery Procedures and the Impact of Residents on Outcome. JOURNAL OF SURGICAL EDUCATION 2024; 81:1683-1690. [PMID: 39293193 DOI: 10.1016/j.jsurg.2024.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 08/12/2024] [Accepted: 08/20/2024] [Indexed: 09/20/2024]
Abstract
BACKGROUND The study is intended to show that the operative quality of a resident in orthopedic trauma surgery is comparable to that of a senior physician in the most common orthopaedic trauma surgeries (Plate osteosynthesis in ankle fractures and distal radius fractures, ESIN in pediatric forearm fractures, implantation of a proximal femoral nail in pertrochanteric femur fractures and hemiarthroplasty in femoral neck fractures) with appropriate supervision by a senior physician. With only minimal deviations in the operating time, which is becoming increasingly relevant in everyday clinical practice, surgical training of residents could be supported. MATERIAL AND METHODS 200 patients of the above-mentioned fracture patterns each, who were treated surgically between January 1, 2016 and December 31, 2020, were detected and categorized. In particular, a qualitative characteristic was determined for each fracture on the basis of the standard pre and postoperative X-rays taken during surgery and statistically evaluated with the surgery time, the fracture classification and the training status of the anonymized surgeon. Anonymized x-rays were evaluated by 2 senior physicians and 2 residents. RESULTS Operations were performed by residents in 33.5 % of the cases (ankle fractures 42.0%; distal radius fractures 30.5%; pediatric forearm fractures 30.5%; pertrochanteric femur fractures 50.5%; femoral neck fractures 14.0%). Surgical complication rate was 4.8% in the resident group and 9.0% in the attending surgeon group. Revision surgeries were performed in 2.1% of resident cases, and in 4.1% of attending surgeon cases. In the resident group, time of surgery was 7.4 min longer for ankle fractures, 4.4 min for distal radius fractures, 2.8 min for forearm fractures, 2.3 min longer in proximal femur fractures 8.2 min longer for femoral neck fractures. No statistically significant difference in radiological outcome was observed in any of the groups after evaluation of the x-rays. CONCLUSION This study shows that only slightly more than one third of all mentioned operations are performed by residents, although there is no statistical difference in quality. The operating time is extended on average by only 5 minutes. The surgical complication rate as well as the revision rate is higher in the group of senior physicians, whereby the more complicated fractures were treated by them. Resident involvement in trauma surgery is therefore not associated with increased morbidity or mortality of patients.
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Affiliation(s)
- Raffael Cintean
- Department of Trauma-, Hand-, and Reconstructive Surgery, Ulm University, Ulm, Germany.
| | - Christina Degenhart
- Department of Trauma-, Hand-, and Reconstructive Surgery, Ulm University, Ulm, Germany
| | - Carlos Pankratz
- Department of Trauma-, Hand-, and Reconstructive Surgery, Ulm University, Ulm, Germany
| | - Florian Gebhard
- Department of Trauma-, Hand-, and Reconstructive Surgery, Ulm University, Ulm, Germany
| | - Konrad Schütze
- Department of Trauma-, Hand-, and Reconstructive Surgery, Ulm University, Ulm, Germany
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Barile F, Ruffilli A, Cerasoli T, Manzetti M, Viroli G, Traversari M, Mazzotti A, Faldini C. Comparison Between Resident and Attending Surgeons as Assistants on Adolescent Idiopathic Scoliosis Surgery: No Differences in Outcomes, Complications Rate, or Pedicle Screw Placement Accuracy. Clin Spine Surg 2024:01933606-990000000-00343. [PMID: 39087678 DOI: 10.1097/bsd.0000000000001670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 06/28/2024] [Indexed: 08/02/2024]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of the present study was to determine if the level of training of the first assistant (resident or attending surgeon) has an influence on the radiographic outcome of AIS surgery and on the accuracy rate of the pedicle screws placement. SUMMARY OF BACKGROUND DATA Adolescent idiopathic scoliosis (AIS) surgery is a challenging procedure that requires a dedicated team of skilled professionals. Therefore, understanding the learning curve is of outstanding importance to guarantee the best outcomes and the highest safety to the patients. METHODS A retrospective analysis of patients who underwent surgery for AIS with a minimum follow-up of 2 years was conducted. All patients were operated by an experienced spine surgeon, assisted by and attending surgeon (group A) or a senior resident (group B). Radiographic outcomes were assessed. Through postoperative CT scan, accuracy of pedicle screw placement was measured (using Gertzbein-Robbins classification). Groups were then statistically compared. RESULTS A total of 120 patients were included (mean age 15.3±3.39 y, major curve Cobb 60.7±11.9 degrees). No difference was found between groups in terms of preoperative characteristics and postoperative radiographic (correction rate, thoracic kyphosis, screw density) outcomes or complications. Operative time and estimated blood loss were significantly higher in Group B (P=0.045 and P=0.024, respectively). Of the 2746 pedicle screws inserted (1319 group A and 1427 group B), 2452 had a perfect intrapedicular trajectory (absolute accuracy of 89.29%) and 2697 had a breach <2 mm (relative accuracy of 97.56%). No difference was found among groups in terms of absolute or relative accuracy (P=0.06 and P=0.23, respectively). CONCLUSIONS AIS cases assisted by senior residents have longer operative time and higher blood loss, but this does not negatively affect the overall radiographic outcome and does not place the patient at increased risk of complications. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Francesca Barile
- Department of Biomedical and Neuromotor Science, University of Bologna, 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli Bologna Italy
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Okubo T, Nagoshi N, Kono H, Kobayashi Y, Tsuji O, Aoyama R, Isogai N, Ishihara S, Takeda K, Ozaki M, Suzuki S, Matsumoto M, Nakamura M, Watanabe K, Ishii K, Yamane J. Comparison of Surgical Outcomes After Posterior Decompression by Junior or Senior Surgeons for Patients With Cervical Ossification of the Posterior Longitudinal Ligament: Results From Retrospective Multicenter Cohort Study. Global Spine J 2024:21925682241260725. [PMID: 38831702 DOI: 10.1177/21925682241260725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024] Open
Abstract
STUDY DESIGN Retrospective multicenter study. OBJECTIVES To investigate surgical outcomes following posterior decompression for cervical ossification of the posterior longitudinal ligament (OPLL) when performed by board-certified spine (BCS) or non-BCS (NBCS) surgeons. METHODS We included 203 patients with cervical OPLL who were followed for a minimum of 1 year after surgery. Demographic information, medical history, and imaging findings were collected. Clinical outcomes were assessed preoperatively and at the final follow-up using the Japanese Orthopedic Association (JOA) score and the visual analog scale (VAS) for the neck. We compared outcomes between BCS surgeons, who must meet several requirements, including experience in more than 300 spinal surgeries, and NBCS surgeons. RESULTS BCS surgeons performed 124 out of 203 cases, while NBCS surgeons were primary in 79 cases, with 73.4% were directly supervised by a BCS surgeon. There was no statistically significant difference in surgical duration, estimated blood loss, and perioperative complication rates between the BCS and NBCS groups. Moreover, no statistically significant group differences were observed in each position of the C2-7 angle and cervical range of motion at preoperation and the final follow-up. Preoperative and final follow-up JOA scores, VAS for the neck, and JOA score recovery rate were comparable between the two groups. CONCLUSIONS Surgical outcomes, including functional recovery, complication rates, and cervical dynamics, were comparable between the BCS and NBCS groups. Consequently, posterior decompression for cervical OPLL is considered safe and effective when conducted by junior surgeons who have undergone training and supervision by experienced spine surgeons.
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Affiliation(s)
- Toshiki Okubo
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Narihito Nagoshi
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Hitoshi Kono
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Department of Orthopedic Surgery, Keiyu Orthopedic Hospital, Tatebayashi, Japan
| | - Yoshiomi Kobayashi
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Department of Orthopedic Surgery, Japan Red Cross Shizuoka Hospital, Shizuoka, Japan
- Department of Orthopedic Surgery, National Hospital Organization Murayama Medical Center, Tokyo, Japan
| | - Osahiko Tsuji
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Department of Orthopedic Surgery, Saitama Medical Center, Saitama, Japan
| | - Ryoma Aoyama
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Department of Orthopedic Surgery, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan
| | - Norihiro Isogai
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Spine and Spinal Cord Center, International University of Health and Welfare (IUHW) Mita Hospital, Tokyo, Japan
| | - Shinichi Ishihara
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Spine and Spinal Cord Center, International University of Health and Welfare (IUHW) Mita Hospital, Tokyo, Japan
- Department of Orthopedic Surgery, Subaru Health Insurance Society Ota Memorial Hospital, Ota, Japan
| | - Kazuki Takeda
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Masahiro Ozaki
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Satoshi Suzuki
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Morio Matsumoto
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Masaya Nakamura
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Kota Watanabe
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Ken Ishii
- Keio Spine Research Group (KSRG), Tokyo, Japan
- New Spine Clinic Tokyo, Tokyo, Japan
| | - Junichi Yamane
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Department of Orthopedic Surgery, National Hospital Organization Murayama Medical Center, Tokyo, Japan
- Department of Orthopedic Surgery, Kanagawa Prefectural Police Association Keiyu Hospital, Yokohama, Japan
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Lee A, Lucasti C, Scott MM, Patel DV, Kohut K, Pavlesen S, Bayers-Thering M, Hamill CL. The Surgical Outcomes of Pedicle Subtraction Osteotomy per Different First Assistant: Retrospective Analysis of 312 Cases. J Am Acad Orthop Surg 2024; 32:e33-e43. [PMID: 37467386 DOI: 10.5435/jaaos-d-23-00157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/19/2023] [Indexed: 07/21/2023] Open
Abstract
INTRODUCTION Pedicle subtraction osteotomies (PSOs) are complex spinal deformity surgeries that are associated with high complication rates. They are typically done by an experienced spine surgeon with another attending, resident, or physician assistant serving as the first assistant. The purpose of this study was to determine whether selecting a surgical team for single-level PSO based on case difficulty and fusion length could equalize intraoperative and perioperative outcomes among three groups: dual-attending (DA), attending and orthopaedic resident (RS), and attending and physician assistant (PA). METHODS This study was a retrospective cohort analysis of 312 patients undergoing single-level thoracic or lumbar PSO from January 2007 to December 2020 by a fellowship-trained orthopaedic spine surgeon. Demographic, intraoperative, and perioperative data within 30 days and 2 years of the index procedure were analyzed. RESULTS Patient demographics did not markedly differ between surgical groups. The mean cohort age was 64.5 years with BMI 31.9 kg/m 2 . Patients with the DA approach had a significantly longer surgical time (DA = 412 min vs. resident = 372 min vs. physician assistant = 323 min; P < 0.001). Patients within the DA group experienced a significantly lower rate of infection (DA = 2.1% [3/140] vs. RS = 7.9% [9/114] vs. PA = 1.7% [1/58], P = 0.043), surgical complication rate (DA = 26% [37/140] vs. RS = 41% [47/114] vs. PA = 33% [19/58], P < 0 .001), and readmission rate (DA = 6.4% [9/140] vs. RS = 12.3% [14/114] vs. PA = 19% [11/58] P = 0.030) within 30 days of surgery. No notable differences were observed among groups in 2-year complication, infection, readmission, or revision surgery rates. CONCLUSIONS These study results support the DA surgeon approach. Resident involvement, even in less complex cases, can still negatively affect perioperative outcomes. Additional selection criteria development is needed.
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Affiliation(s)
- Andrew Lee
- From the Department of Orthopaedic Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
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Borja AJ, Ahmad HS, Tomlinson SB, Na J, McClintock SD, Welch WC, Marcotte PJ, Ozturk AK, Malhotra NR. "July Effect" in Spinal Fusions: A Coarsened Exact-Matched Analysis. Neurosurgery 2023; 92:623-631. [PMID: 36700756 DOI: 10.1227/neu.0000000000002256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 09/21/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Few neurosurgical studies examine the July Effect within elective spinal procedures, and none uses an exact-matched protocol to rigorously account for confounders. OBJECTIVE To evaluate the July Effect in single-level spinal fusions, after coarsened exact matching of the patient cohort on key patient characteristics (including race and comorbid status) known to independently affect neurosurgical outcomes. METHODS Two thousand three hundred thirty-eight adult patients who underwent single-level, posterior-only lumbar fusion at a single, multicenter university hospital system were retrospectively enrolled. Primary outcomes included readmissions, emergency department visits, reoperation, surgical complications, and mortality within 30 days of surgery. Logistic regression was used to analyze month as an ordinal variable. Subsequently, outcomes were compared between patients with surgery at the beginning vs end of the academic year (ie, July vs April-June), before and after coarsened exact matching on key characteristics. After exact matching, 99 exactly matched pairs of patients (total n = 198) were included for analysis. RESULTS Among all patients, operative month was not associated with adverse postoperative events within 30 days of the index operation. Furthermore, patients with surgeries in July had no significant difference in adverse outcomes. Similarly, between exact-matched cohorts, patients in July were observed to have noninferior adverse postoperative events. CONCLUSION There was no evidence suggestive of a July Effect after single-level, posterior approach spinal fusions in our cohort. These findings align with the previous literature to imply that teaching hospitals provide adequate patient care throughout the academic year, regardless of how long individual resident physician assistants have been in their particular role.
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Affiliation(s)
- Austin J Borja
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hasan S Ahmad
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Samuel B Tomlinson
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jianbo Na
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- McKenna EpiLog Fellowship in Population Health, at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Scott D McClintock
- The West Chester Statistical Institute and Department of Mathematics, West Chester University, West Chester, Pennsylvania, USA
| | - William C Welch
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paul J Marcotte
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ali K Ozturk
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Neil R Malhotra
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- McKenna EpiLog Fellowship in Population Health, at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Alexander B, Sowers M, Jacob R, McGwin G, Maffulli N, Naranje S. The Impact of Resident Involvement on Patient Outcomes in Revision Total Hip Arthroplasty. Rev Bras Ortop 2023; 58:133-140. [PMID: 36969789 PMCID: PMC10038725 DOI: 10.1055/s-0041-1736469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 09/02/2021] [Indexed: 10/19/2022] Open
Abstract
Objective The aim of the present study was to determine the influence of resident involvement on acute complication rates in revision total hip arthroplasty (THA). Methods Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, 1,743 revision THAs were identified from 2008 to 2012; 949 of them involved a resident physician. Demographic information including gender and race, comorbidities including lung disease, heart disease and diabetes, operative time, length of stay, and acute postoperative complications within 30 days were analyzed. Results Resident involvement was not associated with a significant increase in the risk of acute complications. Total operative time demonstrated a statistically significant association with the involvement of a resident (161.35 minutes with resident present, 135.07 minutes without resident; p < 0.001). There was no evidence that resident involvement was associated with a longer hospital stay (5.61 days with resident present, 5.22 days without resident; p = 0.46). Conclusion Involvement of an orthopedic resident during revision THA does not appear to increase short-term postoperative complication rates, despite a significant increase in operative times.
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Affiliation(s)
- Bradley Alexander
- Divisão de Cirurgia Ortopédica, Universidade do Alabama em Birmingham, Birmingham, Alabama, Estados Unidos
| | - Mackenzie Sowers
- Divisão de Cirurgia Ortopédica, Universidade do Alabama em Birmingham, Birmingham, Alabama, Estados Unidos
| | - Roshan Jacob
- Divisão de Cirurgia Ortopédica, Universidade do Alabama em Birmingham, Birmingham, Alabama, Estados Unidos
| | - Gerald McGwin
- Departamento de Epidemiologia, Universidade do Alabama em Birmingham, Universidade Boulevard Birmingham, Alabama, Estados Unidos
| | - Nicola Maffulli
- Departamento de Distúrbios Musculoesqueléticos, Faculdade de Medicina e Cirurgia, Universidade de Salerno, Baronissi, Itália
| | - Sameer Naranje
- Divisão de Cirurgia Ortopédica, Universidade do Alabama em Birmingham, Birmingham, Alabama, Estados Unidos
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Effect of Fellow Involvement and Experience on Patient Outcomes in Spine Surgery. J Am Acad Orthop Surg 2022; 30:831-840. [PMID: 35421018 DOI: 10.5435/jaaos-d-21-01019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 03/06/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Investigations in spine surgery have demonstrated that trainee involvement correlates with increased surgical time, readmissions, and revision surgeries; however, the specific effects of spine fellow involvement remain unelucidated. This study aims to investigate the isolated effect of fellow involvement on surgical timing and patient-reported outcomes measures (PROMs) after spine surgery and evaluate how surgical outcomes differ by fellow experience. METHODS All patients aged 18 years or older who underwent primary or revision decompression or fusion for degenerative diseases and/or spinal deformity between 2017 and 2019 at a single academic institution were retrospectively identified. Patient demographics, surgical factors, intraoperative timing, transfusion status, length of stay (LOS), readmissions, revision rate, and preoperative and postoperative PROMs were recorded. Surgeries were divided based on spine fellow participation status and occurrence in the start or end of fellowship training. Univariate and multivariate analyses compared outcomes across fellow involvement and fellow experience groups. RESULTS A total of 1,108 patients were included. Age, preoperative diagnoses, number of fusion levels, and surgical approach differed markedly by fellow involvement. Fellow training experience groups differed by patient smoking status, preoperative diagnosis, and surgical approach. On univariate analysis, spine fellow involvement was associated with extended total theater time, induction start to cut time, cut to close time, and LOS. Increased spine fellow training was associated with reduced cut to close time and LOS. On regression, fellow involvement predicted cut to close extension while increased fellow training experience predicted reduction in cut to close time, both independent of surgical factors and assisting residents or physician assistants. Transfusions, readmissions, revision rate, and PROMs did not differ markedly by fellow involvement or experience. CONCLUSION Spine fellow participation predicted extended procedural duration. However, the presence of a spine fellow did not affect long-term postoperative outcomes. Furthermore, increased fellow training experience predicted decreased procedural time, underscoring a learning effect. AVAILABILITY OF DATA AND MATERIAL The data sets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. LEVEL OF EVIDENCE Level 3.
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Correlation between Scoliosis Flexibility Degree on Preoperative Imaging with Postoperative Curve Correction and Mechanical Complications. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12147305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
(1) Background: In the preoperative planning stage of scoliosis surgery, it is routine to use radiographs obtained with and without traction to observe the curve flexibility in order to estimate curve correction, but its association with mechanical complications is not completely understood. (2) Methods: Retrospective cohort study of all patients undergoing infantile, congenital, neuromuscular or idiopathic adolescent scoliosis correction surgery at a single institution between 2015 and 2019, with a minimum follow-up of 24 months. Associations between qualitative variables were tested with the chi-square test. The association between qualitative and quantitative variables were tested with the Mann–Whitney test, and correlations between quantitative variables was tested with Spearman’s correlation. (3) Results: A total of 330 patients, 88 males and 242 females, with a mean age of 16.98 years at surgery, were included. The mean value of preoperative main curves, its flexibility and postoperative value were 54.44 degrees, 21.73 degrees and 18.08 degrees, respectively. (4) Conclusions: Preoperative spinal X-ray examination with traction or bending films is a reasonable option for assessing scoliotic curve flexibility, and patients with neuromuscular scoliosis who are not ambulatory can be informed of the increased risks of late mechanical complications.
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Meyer MA, Tarabochia MA, Goh BC, Hietbrink F, Houwert RM, Dyer GSM. The Impact of Resident Involvement on Outcomes and Costs in Elective Hand and Upper Extremity Surgery. J Hand Surg Am 2022:S0363-5023(22)00121-6. [PMID: 35461739 DOI: 10.1016/j.jhsa.2022.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 12/15/2021] [Accepted: 02/02/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to assess the impact of resident involvement on periprocedural outcomes and costs after common procedures performed at an academic hand surgical practice. METHODS A retrospective review was performed in all patients undergoing 7 common elective upper extremity procedures between January 2008 and December 2018: carpal tunnel release, distal radius open reduction and internal fixation (ORIF), trigger finger release, thumb carpometacarpal arthroplasty, phalanx closed reduction and percutaneous pinning, cubital tunnel release, and olecranon ORIF. The medical record was reviewed to determine the impact of surgical assistants (resident, fellow, or physician assistant) on periprocedural outcomes, periprocedural costs, and 1-year postoperative outcomes. The involvement of surgical trainees operating under direct supervision was compared with the entire operation performed by the attending surgeon with a physician assistant present. RESULTS A total of 396 procedures met the inclusion criteria. Analysis of the whole study sample revealed low rates of intraoperative complications, wound complications, medical complications, readmissions, and mortality. Subgroup analysis of carpal tunnel releases revealed significantly greater tourniquet times for residents compared with physician assistants (7 ± 2 min, 6 ± 1 min), as well as longer overall operating room times for residents compared to fellows or physician assistants (17 ± 5 min, 13 ± 3 min, 12 ± 3 min). Operating room times for distal radius ORIF were significantly greater among residents compared to fellows or physician assistants (68 ± 19 min, 57 ± 17 min, 56 ± 14 min). There were no differences in any other perioperative metrics or periprocedural costs for the trigger finger release or cubital tunnel release cohorts. CONCLUSIONS Resident involvement in select upper extremity procedures can lengthen operative times but does not have an impact on blood loss or operating room costs. CLINICAL RELEVANCE Surgeons should be aware that having a resident assistant slightly increases operative times in elective hand surgery.
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Affiliation(s)
- Maximilian A Meyer
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA; Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.
| | | | - Brian C Goh
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - R Marijn Houwert
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - George S M Dyer
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA
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Kagan R, Hart C, Hiratzka SL, Mirarchi AJ, Mirza AJ, Friess DM. Does Resident Participation in the Surgical Fixation of Hip Fractures Increase Operative Time or Affect Outcomes? JOURNAL OF SURGICAL EDUCATION 2021; 78:1269-1274. [PMID: 33281076 DOI: 10.1016/j.jsurg.2020.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 08/20/2020] [Accepted: 11/20/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Surgical fixation of hip fractures is a common procedure at teaching hospitals with resident support and in community hospitals. OBJECTIVE We evaluated to what extent participation by residents in hip fracture fixation affects operative times or outcomes. SETTING Operations were performed by three surgeons who operate at a teaching hospital with resident support, and at a community hospital without residents in the same metropolitan area. PARTICIPANTS We performed a retrospective analysis of operative time and early post-operative outcomes on a series of 314 patients with hip fractures (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association A1-3, B1-3) treated with surgical fixation between April 2012 and March 2015; 177 patients at the community hospital, and 137 at the teaching hospital. METHODS Multivariate regression assessed the effect of hospital type, adjusting for age, gender, American Society of Anesthesiologist classification, and Charlson comorbidity index. RESULTS We found lower median operative time at the community hospital than the teaching hospital (46 minutes, 95% confidence interval [CI] = [43, 52] versus 75 minutes, 95% CI = [70, 81]) and lower estimated blood loss (177.3 mL, 95% CI=[158.6, 195.1] versus 234.8 mL, 95% CI = [196.4, 273.6]), but no differences in transfusion requirement, length of stay, or discharge to skilled nursing facility. Adjusted odds ratio for thirty-day mortality at the teaching hospital was 5.44 (95% CI = [1.22, 24.1]). CONCLUSION We found longer operative times and elevated estimated blood loss with resident involvement in surgical fixation of hip fractures. There was a difference in 30-day mortality between the groups, although this cannot simply be attributed to resident involvement as there are many other factors related to mortality.
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Affiliation(s)
- Ryland Kagan
- Oregon Health and Science University, Department of Orthopaedics and Rehabilitation, Portland, Oregon.
| | - Christopher Hart
- University of California Los Angeles, Department of Orthopaedic Surgery, Los Angeles, California
| | - Shannon L Hiratzka
- Oregon Health and Science University, Department of Orthopaedics and Rehabilitation, Portland, Oregon
| | - Adam J Mirarchi
- Oregon Health and Science University, Department of Orthopaedics and Rehabilitation, Portland, Oregon
| | | | - Darin M Friess
- Oregon Health and Science University, Department of Orthopaedics and Rehabilitation, Portland, Oregon
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Chan AK, Patel AB, Bisson EF, Bydon M, Glassman SD, Foley KT, Shaffrey CI, Potts EA, Shaffrey ME, Coric D, Knightly JJ, Park P, Wang MY, Fu KMG, Slotkin JR, Asher AL, Virk MS, Kerezoudis P, Alvi MA, Guan J, Choy W, Haid RW, Mummaneni PV. "July Effect" Revisited: July Surgeries at Residency Training Programs are Associated with Equivalent Long-term Clinical Outcomes Following Lumbar Spondylolisthesis Surgery. Spine (Phila Pa 1976) 2021; 46:836-843. [PMID: 33394990 DOI: 10.1097/brs.0000000000003903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective analysis of a prospective registry. OBJECTIVE We utilized the Quality Outcomes Database (QOD) registry to investigate the "July Effect" at QOD spondylolisthesis module sites with residency trainees. SUMMARY OF BACKGROUND DATA There is a paucity of investigation on the long-term outcomes following surgeries involving new trainees utilizing high-quality, prospectively collected data. METHODS This was an analysis of 608 patients who underwent single-segment surgery for grade 1 degenerative lumbar spondylolisthesis at 12 high-enrolling sites. Surgeries were classified as occurring in July or not in July (non-July). Outcomes collected included estimated blood loss, length of stay, operative time, discharge disposition, complications, reoperation and readmission rates, and patient-reported outcomes (Oswestry Disability Index [ODI], Numeric Rating Scale [NRS] Back Pain, NRS Leg Pain, EuroQol-5D [EQ-5D] and the North American Spine Society [NASS] Satisfaction Questionnaire). Propensity score-matched analyses were utilized to compare postoperative outcomes and complication rates between the July and non-July groups. RESULTS Three hundred seventy-one surgeries occurred at centers with a residency training program with 21 (5.7%) taking place in July. In propensity score-matched analyses, July surgeries were associated with longer operative times ( average treatment effect = 22.4 minutes longer, 95% confidence interval 0.9-449.0, P = 0.041). Otherwise, July surgeries were not associated with significantly different outcomes for the remaining perioperative parameters (estimated blood loss, length of stay, discharge disposition, postoperative complications), overall reoperation rates, 3-month readmission rates, and 24-month ODI, NRS back pain, NRS leg pain, EQ-5D, and NASS satisfaction score (P > 0.05, all comparisons). CONCLUSION Although July surgeries were associated with longer operative times, there were no associations with other clinical outcomes compared to non-July surgeries following lumbar spondylolisthesis surgery. These findings may be due to the increased attending supervision and intraoperative education during the beginning of the academic year. There is no evidence that the influx of new trainees in July significantly affects long-term patient-centered outcomes.Level of Evidence: 3.
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Affiliation(s)
- Andrew K Chan
- Department of Neurological Surgery, University of California, San Francisco, Ca
| | - Arati B Patel
- Department of Neurological Surgery, University of California, San Francisco, Ca
| | - Erica F Bisson
- Department of Neurological Surgery, University of Utah, Salt Lake City, UT
| | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | | | - Kevin T Foley
- Department of Neurological Surgery, University of Tennessee Health Science Center, Semmes Murphey Neurologic and Spine Institute, Memphis, TN
| | | | - Eric A Potts
- Goodman Campbell Brain and Spine, Indianapolis, IN
| | - Mark E Shaffrey
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA
| | - Domagoj Coric
- Neuroscience Institute, Carolinas HealthCare System and Carolina NeuroSurgery and Spine Associates, Charlotte, NC
| | | | - Paul Park
- Department of Neurological Surgery, University of Michigan, Ann Arbor, MI
| | - Michael Y Wang
- Departments of Neurological Surgery and Rehab Medicine, University of Miami, FL
| | - Kai-Ming G Fu
- Department of Neurological Surgery, Weill Cornell Medical Center, New York, NY
| | | | - Anthony L Asher
- Neuroscience Institute, Carolinas HealthCare System and Carolina NeuroSurgery and Spine Associates, Charlotte, NC
| | - Michael S Virk
- Department of Neurological Surgery, Weill Cornell Medical Center, New York, NY
| | | | - Mohammed A Alvi
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Jian Guan
- Department of Neurological Surgery, University of Utah, Salt Lake City, UT
| | - Winward Choy
- Department of Neurological Surgery, University of California, San Francisco, Ca
| | | | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, Ca
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Divi SN, Goyal DK, Hoffman E, Conaway WK, Galtta M, Bowles DR, Houlihan NV, Bechay JF, McEntee RM, Kaye ID, Kurd MF, Woods BI, Radcliff KE, Rihn JA, Anderson DG, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. How Does the Presence of a Surgical Trainee Impact Patient Outcomes in Lumbar Fusion Surgery? Int J Spine Surg 2021; 15:471-477. [PMID: 34074745 PMCID: PMC8176829 DOI: 10.14444/8033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND While the impact of trainee involvement in other surgical fields is well established, there is a paucity of literature assessing this relationship in orthopaedic spine surgery. The goal of this study was to further elucidate this relationship. METHODS A retrospective cohort study was initiated on patients undergoing 1-3 level lumbar spine fusion at a single academic center. Operative reports from cases were examined, and patients were divided into 2 groups depending on whether a fellow or resident (F/R) or a physician's assistant (PA) was used as the primary assist. Patients with less than 1-year follow-up were excluded. Multiple linear regression was used to assess change in each patient-reported outcome, and multiple binary logistic regression was used to determine significant predictors of revision, infection, and 30- or 90-day readmission. RESULTS One hundred and seventy-two patients were included in the F/R group compared with 178 patients in the PA group. No differences existed between groups for total surgery time, length of stay, 30- or 90-day readmissions, infection, or revision rates. No differences existed between groups in terms of patient-reported outcomes preoperatively or postoperatively. In addition, presence of a surgical trainee was not a significant predictor of patient outcomes or rates of infection, overall revision, or 30- and 90-day readmission rates. CONCLUSIONS The results of this study indicate the presence of an orthopaedic spine F/R does not increase complication rates and does not affect short-term patient-reported outcomes in lumbar decompression and fusion surgery. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Srikanth N. Divi
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Dhruv K.C. Goyal
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Eve Hoffman
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - William K. Conaway
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Matt Galtta
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Daniel R. Bowles
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Nathan V. Houlihan
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Joseph F. Bechay
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Richard M. McEntee
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - I. David Kaye
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Mark F. Kurd
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Barrett I. Woods
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Kris E. Radcliff
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jeffery A. Rihn
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - D. Greg Anderson
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Alan S. Hilibrand
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Christopher K. Kepler
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Alexander R. Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Gregory D. Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
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Comparison of a dual-surgeon versus single-surgeon approach for scoliosis surgery: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:740-748. [PMID: 33439334 DOI: 10.1007/s00586-021-06717-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 12/09/2020] [Accepted: 01/01/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Corrective surgery for scoliosis is a complex and challenging prospect for experienced spine surgeons due to the prolonged duration of surgery and the significant level of technical skill and expertise required. Traditionally, shorter operative time and lower blood loss have correlated well with improved outcomes and as such, efforts have been made to affect these metrics including the use of two attending surgeons for major cases in preference to one. This systematic review and meta-analysis assessed the available literature to further clarify the potential benefit that adopting a dual-surgeon approach offers over single-surgeon operations. METHODS A systematic review and meta-analysis assessed the effect of dual-surgeon operating compared to single-surgeon with respect to a number of indicators including blood loss, operative duration and length of hospital stay. In addition, we evaluated whether blood transfusion or complication rates differed between the two groups. RESULT Seven studies met our inclusion criteria. Mean difference indicated shorter duration of surgery (- 90.5 min, 95% CI [- 103.3, - 77.6]) and a lower blood loss (- 379.1, 95% CI [- 572.2, - 230.9]) in the dual-surgeon group compared to the single-surgeon group. Six studies reported mean length of stay and also favoured the dual-surgeon group. CONCLUSION This review observed that there are no randomised control trials evaluating dual-surgeon versus single-surgeon operating for scoliosis. We provide aggregated data and analysis of available literature, suggesting that outcomes in complex scoliosis surgery may be improved by adopting a dual-surgeon approach. LEVEL OF EVIDENCE III.
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14
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Are Patient Outcomes Affected by the Presence of a Fellow or Resident in Lumbar Decompression Surgery? Spine (Phila Pa 1976) 2021; 46:35-40. [PMID: 33315362 DOI: 10.1097/brs.0000000000003721] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of this study was to determine whether the presence of a fellow or resident (F/R) compared to a physician assistant (PA) affected surgical variables or short-term patient outcomes. SUMMARY OF BACKGROUND DATA Although orthopedic spine fellows and residents must participate in minimum number of decompression surgeries to gain competency, the impact of trainee presence on patient outcomes has not been assessed. METHODS One hundred and seventy-one patients that underwent a one- to three-level lumbar spine decompression procedure at a high-volume academic center were retrospectively identified. Operative reports from all cases were examined and patients were placed into one of two groups based on whether the first assist was a F/R or a PA. Univariate analysis was used to compare differences in total surgery duration, 30-day and 90-day readmissions, infection and revision rates, patient-reported outcome measures (Short Form-12 Physical Component Score and Mental Component Score, Oswestry Disability Index, Visual Analog Scale [VAS] Back, VAS Leg) between groups. Multiple linear regression was used to assess change in each patient reported outcome and multiple binary logistic regression was used to determine significant predictors of revision, infection, and 30- or 90-day readmission. RESULTS Seventy-eight patients were included in the F/R group compared to 93 patients in the PA group. There were no differences between groups for total surgery time, 30-day or 90-day readmissions, infection, or revision rates. Using univariate analysis, there were no differences between the two groups pre- or postoperatively (P > 0.05). Using multivariate analysis, presence of a surgical trainee did not significantly influence any patient reported outcome and did not affect infection, revision, or 30- and 90-day readmission rates. CONCLUSION This is one of the first studies to show that the presence of an orthopedic spine fellow or resident does not affect patient short-term outcomes in lumbar decompression surgery. LEVEL OF EVIDENCE 3.
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15
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Basques BA, Saltzman BM, Korber SS, Bolia IK, Mayer EN, Bach BR, Verma NN, Cole BJ, Weber AE. Resident Involvement in Arthroscopic Knee Surgery Is Not Associated With Increased Short-term Risk to Patients. Orthop J Sports Med 2020; 8:2325967120967460. [PMID: 33403211 PMCID: PMC7747120 DOI: 10.1177/2325967120967460] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 06/24/2020] [Indexed: 11/15/2022] Open
Abstract
Background: Whether resident involvement in surgical procedures affects intra- and/or postoperative outcomes is controversial. Purpose/Hypothesis: The purpose of this study was to compare operative time, adverse events, and readmission rate for arthroscopic knee surgery cases with and without resident involvement. We hypothesized that resident involvement would not negatively affect these variables. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of the prospectively maintained National Surgical Quality Improvement Program was performed. Patients who underwent arthroscopic knee surgery between 2005 and 2012 were identified. Multivariate Poisson regression with robust error variance was used to compare the rates of postoperative adverse events and readmission within 30 days between cases with and without resident involvement. Multivariate linear regression was used to compare operative time between cohorts. Because of multiple statistical comparisons, a Bonferroni correction was used, and statistical significance was set at P < .004. Results: A total of 29,539 patients who underwent arthroscopic knee surgery were included in the study, and 11.3% of these patients had a resident involved with the case. The overall rate of adverse events was 1.62%. On multivariate analysis, resident involvement was not associated with increased rates of adverse events or readmission. Resident cases had a mean 6-minute increase in operative time (P < .001). Conclusion: Overall, resident involvement in arthroscopic knee surgery was not associated with an increased risk of adverse events or readmission. Resident involvement was associated with only a mean increased operative time of 6 minutes, a difference that is not likely to be clinically significant. These results support the safety of resident involvement with arthroscopic knee surgery.
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Affiliation(s)
| | - Bryan M. Saltzman
- OrthoCarolina Sports Medicine Center, Charlotte, North Carolina, USA
| | - Shane S. Korber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Ioanna K. Bolia
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Erik N. Mayer
- Department of Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, California, USA
| | | | | | - Brian J. Cole
- Midwest Orthopaedics at Rush, Chicago, Illinois, USA
| | - Alexander E. Weber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
- Alexander E. Weber, MD, USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, 1520 San Pablo Street #2000, Los Angeles, CA 90033, USA ()
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Cheng I, Stienen MN, Medress ZA, Varshneya K, Ho AL, Ratliff JK, Veeravagu A. Single- versus dual-attending strategy for spinal deformity surgery: 2-year experience and systematic review of the literature. J Neurosurg Spine 2020; 33:560-571. [PMID: 32650315 DOI: 10.3171/2020.3.spine2016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 03/31/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Adult spinal deformity (ASD) surgery is complex and associated with high morbidity and complication rates. There is growing evidence in the literature for the beneficial effects of an approach to surgery in which two attending physicians rather than a single attending physician perform surgery for and oversee the surgical care of a single patient in a dual-attending care model. The authors developed a dual-attending care collaboration in August 2017 in which a neurosurgeon and an orthopedic surgeon mutually operated on patients with ASD. METHODS The authors recorded data for 2 years of experience with ASD patients operated on by dual attending surgeons. Analyses included estimated blood loss (EBL), transfusions, length of stay (LOS), discharge disposition, complication rates, emergency room visits and readmissions, subjective health status improvement, and disability (Oswestry Disability Index [ODI] score) and pain (visual analog scale [VAS] score) at last follow-up. In addition, the pertinent literature for dual-attending spinal deformity correction was systematically reviewed. RESULTS The study group comprised 19 of 254 (7.5%) consecutively operated patients who underwent thoracolumbar fusion during the period from January 2017 to June 2019 (68.4% female; mean patient age 65.1 years, ODI score 44.5, VAS pain score 6.8). The study patients were matched by age, sex, anesthesia risk, BMI, smoking status, ODI score, VAS pain score, prior spine surgeries, and basic operative characteristics (type of interbody implants, instrumented segments, pelvic fixation) to 19 control patients (all p > 0.05). There was a trend toward less EBL (mean 763 vs 1524 ml, p = 0.059), fewer intraoperative red blood cell transfusions (mean 0.5 vs 2.3, p = 0.079), and fewer 90-day readmissions (0% vs 15.8%, p = 0.071) in the dual-attending group. LOS and discharge disposition were similar, as were the rates of any < 30-day postsurgery complications, < 90-day postsurgery emergency room visits, and reoperations, and ODI and VAS pain scores at last follow-up (all p > 0.05). At last follow-up, 94.7% vs 68.4% of patients in the dual- versus single-attending group stated their health status had improved (p = 0.036). In the authors' literature search of prior articles on spinal deformity correction, 5 of 8 (62.5%) articles reported lower EBL and 6 of 8 (75%) articles reported significantly lower operation duration in dual-attending cases. The literature contained differing results with regard to complication- or reoperation-sparing effects associated with dual-attending cases. Similar clinical outcomes of dual- versus single-attending cases were reported. CONCLUSIONS Establishing a dual-attending care management platform for ASD correction was feasible at the authors' institution. Results of the use of a dual-attending strategy at the authors' institution were favorable. Positive safety and outcome profiles were found in articles on this topic identified by a systematic literature review.
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Affiliation(s)
| | - Martin N Stienen
- 2Neurosurgery, Stanford University Hospitals and Clinics, Stanford, California
- 3Department of Neurosurgery, University Hospital Zurich; and
- 4Clinical Neuroscience Center, University of Zurich, Switzerland
| | - Zachary A Medress
- 2Neurosurgery, Stanford University Hospitals and Clinics, Stanford, California
| | - Kunal Varshneya
- 2Neurosurgery, Stanford University Hospitals and Clinics, Stanford, California
| | - Allen L Ho
- 2Neurosurgery, Stanford University Hospitals and Clinics, Stanford, California
| | - John K Ratliff
- 2Neurosurgery, Stanford University Hospitals and Clinics, Stanford, California
| | - Anand Veeravagu
- 2Neurosurgery, Stanford University Hospitals and Clinics, Stanford, California
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17
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Sarwahi V, Galina J, Wendolowski S, Dimauro JP, Moguilevich M, Katyal C, Thornhill B, Lo Y, Amaral TD. A dual-team approach benefits standard-volume surgeons, but has minimal impact on outcomes for a high-volume surgeon in AIS patients. Spine Deform 2020; 8:447-453. [PMID: 32026443 DOI: 10.1007/s43390-020-00049-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 11/30/2019] [Indexed: 11/28/2022]
Abstract
STUDY DESIGN Retrospective chart review of prospectively collected data. OBJECTIVE This study seeks to evaluate the effect of number of surgeons, surgeon experience, and surgeon volume on AIS surgery. Recent literature suggests that utilizing two surgeons for spine deformity correction surgery can improve perioperative outcomes. However, the surgeon's experience and surgical volume are likely as important. METHODS AIS patients undergoing PSF from 2009 to 2019 were included. Patient demographics, X-ray and perioperative outcomes were collected and collated based on primary surgeon. Analysis was performed for single versus dual surgeons, surgeon experience (≤ 10 years in practice), and surgical volume (less/greater than 50 cases/year). Median (IQR) values, Wilcoxon Rank Sums test, Kruskal-Wallis test, and Fisher's exact test were utilized. RESULTS 519 AIS cases, performed by 4 surgeons were included. Two surgeons were highly experienced, 1 of whom was also high volume. Five cohorts were studied: a single senior high volume (S1) (n = 302), dual-junior surgeons (DJ) (n = 73), dual senior-junior (SJ) (n = 36), dual-senior (DS) (n = 21) and a single senior, standard-volume surgeon alone (S2) (n = 87). Radiographic parameters were similar between the groups (p > 0.05). Preoperative Cobb was significantly higher for DS compared to S1 (p = 0.034) Pre- and post-op kyphosis were similar (p > 0.05). Cobb correction was similar (p > 0.05). Levels fused, fixation points, anesthesia and surgical times were similar (p > 0.05). When the standard-volume surgeon operated with a second surgeon, radiographic parameters were similar (p > 0.05), but anesthesia time, surgical time, and hospital length of stay were significantly shorter (p < 0.05). Additionally, DJ had significantly shorter anesthesia and operative times (p < 0.001) and length of stay (p < 0.001) compared to S2. CONCLUSION Standard-volume surgeons have better outcomes with a dual surgeon approach. Junior surgeons benefit operating with an experienced surgeon. A high-volume surgeon, however, does not benefit from a dual surgeon approach. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Vishal Sarwahi
- Department of Pediatric Orthopaedics, Center for Advanced Pediatric Orthopaedics, Cohen Children's Medical Center, Northwell Health System, 7 Vermont Drive, New Hyde Park, NY, 11042, USA.
| | - Jesse Galina
- Department of Pediatric Orthopaedics, Center for Advanced Pediatric Orthopaedics, Cohen Children's Medical Center, Northwell Health System, 7 Vermont Drive, New Hyde Park, NY, 11042, USA
| | - Stephen Wendolowski
- Department of Pediatric Orthopaedics, Center for Advanced Pediatric Orthopaedics, Cohen Children's Medical Center, Northwell Health System, 7 Vermont Drive, New Hyde Park, NY, 11042, USA
| | - Jon-Paul Dimauro
- Department of Pediatric Orthopaedics, Center for Advanced Pediatric Orthopaedics, Cohen Children's Medical Center, Northwell Health System, 7 Vermont Drive, New Hyde Park, NY, 11042, USA
| | - Marina Moguilevich
- Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, NY, USA
| | - Chhavi Katyal
- Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, NY, USA
| | - Beverly Thornhill
- Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, NY, USA
| | - Yungtai Lo
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Terry D Amaral
- Department of Pediatric Orthopaedics, Center for Advanced Pediatric Orthopaedics, Cohen Children's Medical Center, Northwell Health System, 7 Vermont Drive, New Hyde Park, NY, 11042, USA
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18
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Phan K, Phan P, Stratton A, Kingwell S, Hoda M, Wai E. Impact of resident involvement on cervical and lumbar spine surgery outcomes. Spine J 2019; 19:1905-1910. [PMID: 31323330 DOI: 10.1016/j.spinee.2019.07.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 07/11/2019] [Accepted: 07/12/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Resident involvement in the operating room is a vital component of their medical education. Conflicting and limited research exists regarding the effects of surgical resident participation on spine surgery patient outcomes. PURPOSE To determine the effect of resident involvement on surgery duration, length of hospital stay and 30-day postoperative complication rates in common spinal surgery using the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database. STUDY DESIGN Multicenter retrospective cohort study. PATIENT SAMPLE A total of 1,441 patients met the inclusion criteria: 1,142 patients had surgeries with an attending physician alone and 299 patients had surgeries with trainee involvement. All anterior cervical or posterior lumbar surgery patients were identified. Patients who had missing trainee involvement information, surgery for cancer, preoperative infection or dirty wound classification, spine fractures, traumatic spinal cord injury, intradural surgery, thoracic surgery, and emergency surgery were excluded. OUTCOME MEASURES The main outcomes of interest analyzed from the ACS-NSQIP database included surgical complications, medical complications, length of hospital stay, and surgery duration. METHODS Propensity score for risk of any complication was calculated to account for baseline characteristic differences between the attending alone and trainee present group. Multivariate logistic regression was used to investigate the impact of resident involvement on surgery duration, length of hospital stay, and 30-day postoperative complication rates. RESULTS After adjusting using the calculated propensity score, the multivariate analysis demonstrated that there was no significant difference in any complication rates between surgeries involving trainees compared to surgeries with attending surgeons alone. Surgery times were found to be significantly longer for surgeries involving trainees. To further explore this relationship, separate analyses were performed for tertiles of predicted surgery duration, cervical or lumbar surgery, fusion or nonfusion, and inpatient or outpatient surgery. The effect of trainee involvement on increasing surgery time remained significant for medium predicted surgery duration, longer predicted surgery duration, cervical surgery, lumbar surgery, fusion surgery, and inpatient surgery. There were no significant differences reported for any other factors. CONCLUSIONS After adjusting for confounding, we demonstrated in a national database that resident involvement in surgeries did not increase complication rates. We demonstrated that surgeries with more complex features may lead to an increase in operative time when trainees are involved. Further study is required to determine how to efficiently integrate resident involvement in surgeries without affecting their medical education.
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Affiliation(s)
- Kim Phan
- Division of Orthopaedic Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Philippe Phan
- Division of Orthopaedic Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Alexandra Stratton
- Division of Orthopaedic Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Stephen Kingwell
- Division of Orthopaedic Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Mohamad Hoda
- Division of Orthopaedic Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Eugene Wai
- Division of Orthopaedic Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
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19
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Giordano L, Oliviero A, Peretti GM, Maffulli N. The presence of residents during orthopedic operation exerts no negative influence on outcome. Br Med Bull 2019; 130:65-80. [PMID: 31049559 DOI: 10.1093/bmb/ldz009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 02/05/2019] [Accepted: 03/26/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Operative procedural training is a key component of orthopedic surgery residency. It is unclear how and whether residents participation in orthopedic surgical procedures impacts on post-operative outcomes. SOURCES OF DATA A systematic search was performed to identify articles in which the presence of a resident in the operating room was certified, and was compared with interventions without the presence of residents. AREAS OF AGREEMENT There is a likely beneficial role of residents in the operating room, and there is only a weak association between the presence of a resident and a worse outcome for orthopedic surgical patients. AREAS OF CONTROVERSY Most of the studies were undertaken in USA, and this represents a limit from the point of view of comparison with other academic and clinical realities. GROWING POINT The data provide support for continued and perhaps increased involvement of resident in orthopedic surgery. AREAS OF RESEARCH To clarify the role of residents on clinically relevant outcomes in orthopedic patients, appropriately powered randomized control trials should be planned.
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Affiliation(s)
- Lorenzo Giordano
- Department of Musculoskeletal Disorder, Faculty of Medicine and Surgery, University of Salerno, Salerno Italy
| | - Antonio Oliviero
- Department of Musculoskeletal Disorder, Faculty of Medicine and Surgery, University of Salerno, Salerno Italy
| | | | - Nicola Maffulli
- Department of Musculoskeletal Disorder, Faculty of Medicine and Surgery, University of Salerno, Salerno Italy.,Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London E1 4DG, UK.,Institute of Science and Technology in Medicine, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, UK
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20
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Talathi NS, Flynn JM, Pahys JM, Samdani AF, Yaszay B, Lonner BS, Miyanji F, Shah SA, Cahill PJ. The Effect of the Level of Training of the First Assistant on the Outcomes of Adolescent Idiopathic Scoliosis Surgery. J Bone Joint Surg Am 2019; 101:e23. [PMID: 30893240 DOI: 10.2106/jbjs.18.00018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND At academic medical centers, residents and fellows play an integral role as surgical first assistants in spinal deformity surgery. However, limited data exist on whether the experience level of the surgical assistant affects outcomes. METHODS We conducted a multicenter, multisurgeon study comparing perioperative and postoperative outcomes after adolescent idiopathic scoliosis (AIS) surgery for the same 11 surgeons who performed cases that were assisted by residents compared with cases that were assisted by fellows. Blood loss, operative time, duration of hospitalization, complication rates, Scoliosis Research Society (SRS)-22 questionnaire scores, and radiographic outcomes were compared between the 2 groups. RESULTS We evaluated outcomes for 347 surgical procedures; 118 cases were assisted by residents and 229 were assisted by fellows. Preoperative radiographic and demographic parameters were not different between the groups. The resident group had significantly more estimated blood loss than the fellow group (939 compared with 762 mL, p = 0.02). Otherwise, the perioperative characteristics were similar between the groups, including the volume of the autologous blood recovery system product that was transfused, the operative time, and the occurrence of intraoperative neuromonitoring changes. Postoperatively, the percentage correction of the Cobb angle, the number of levels that had been fused, the number of days until the discharge criteria had been met, and the rate of major complications were similar between the groups. At the 2-year follow-up, the overall and subdomain SRS-22 questionnaire scores were not different between the groups, except that patients in the resident-assisted group had slightly worse pain scores than those in the fellow-assisted group (4.3 compared with 4.5, p = 0.01). CONCLUSIONS The first assistant's level of training did not affect clinical or radiographic outcomes following AIS surgery. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Nakul S Talathi
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - John M Flynn
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joshua M Pahys
- Shriners Hospitals for Children-Philadelphia, Philadelphia, Pennsylvania
| | - Amer F Samdani
- Shriners Hospitals for Children-Philadelphia, Philadelphia, Pennsylvania
| | - Burt Yaszay
- Rady Children's Hospital-San Diego, San Diego, California
| | | | - Firoz Miyanji
- BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Suken A Shah
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
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Sethi RK, Yanamadala V, Shah SA, Fletcher ND, Flynn J, Lafage V, Schwab F, Heffernan M, DeKleuver M, Mcleod L, Leveque JC, Vitale M. Improving Complex Pediatric and Adult Spine Care While Embracing the Value Equation. Spine Deform 2019; 7:228-235. [PMID: 30660216 DOI: 10.1016/j.jspd.2018.08.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/02/2018] [Accepted: 08/12/2018] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Value in health care is defined as the quotient of outcomes to cost. Both pediatric and adult spinal deformity surgeries are among the most expensive procedures offered today. With high variability in both outcomes and costs in spine surgery today, surgeons will be expected to consider long-term cost effectiveness when comparing treatment options. METHODS We summarize various methods by which value can be increased in complex spine surgery, both through the improvement of outcomes and the reduction of cost. These methods center around standardization, team-based and collaborative approaches, rigorous outcomes tracking through dashboards and registries, and continuous process improvement. RESULTS This manuscript reviews the expert opinion of leading spine specialists on the improvement of safety, quality and improvement of value of pediatric and adult spinal surgery. CONCLUSION Without surgeon leadership in this arena, suboptimal solutions may result from the isolated intervention of regulatory bodies or payer groups. The cooperative development of standardized, team-based approaches in complex spine surgery will lead to the high-quality, high-value care for patients.
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Affiliation(s)
- Rajiv K Sethi
- Virginia Mason Medical Center, University of Washington, 1100 9th Ave, Seattle, WA 98101, USA.
| | - Vijay Yanamadala
- Virginia Mason Medical Center, University of Washington, 1100 9th Ave, Seattle, WA 98101, USA; and Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Suken A Shah
- Dupont Hospital for Children, 1600 Rockland Rd, Wilmington, DE 19803, USA
| | | | - John Flynn
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Virginie Lafage
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021
| | - Frank Schwab
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021
| | | | - Marinus DeKleuver
- Sint Maartenskliniek, Radboud University Medical Center, PO Box 9011, 6500 GM, Nijmegen, the Netherlands
| | - Lisa Mcleod
- University of Colorado Denver, 1201 Larimer St, Denver, CO 80204, USA
| | - Jean Christophe Leveque
- Virginia Mason Medical Center, University of Washington, 1100 9th Ave, Seattle, WA 98101, USA
| | - Michael Vitale
- Morgan Stanley Children's Hospital, Columbia University, 3959 Broadway, New York, NY 10032, USA
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Nagoshi N, Iwanami A, Isogai N, Ishikawa M, Nojiri K, Tsuji T, Daimon K, Takeuchi A, Tsuji O, Okada E, Fujita N, Yagi M, Watanabe K, Nakamura M, Matsumoto M, Ishii K, Yamane J. Does Posterior Cervical Decompression Conducted by Junior Surgeons Affect Clinical Outcomes in the Treatment of Cervical Spondylotic Myelopathy? Results From a Multicenter Study. Global Spine J 2019; 9:25-31. [PMID: 30775205 PMCID: PMC6362553 DOI: 10.1177/2192568218756329] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective multicenter study. OBJECTIVES To evaluate the outcomes of posterior cervical decompression for cervical spondylotic myelopathy (CSM) when performed by board-certified spine (BCS) or non-BCS (NBCS) surgeons. METHODS We reviewed outcomes for 675 patients who underwent surgery for CSM, were followed at least 1 year after surgery, and were assessed preoperatively and at final follow-up by Japanese Orthopaedic Association (JOA) scores and by the visual analog scale (VAS) for the neck. Cervical alignment was assessed on radiographs by C2-C7 angles, and range of motion (ROM) by extension minus flexion C2-C7 angles. We compared outcomes for BCS surgeons, who must meet several requirements, including experience in more than 300 spinal surgeries, and for NBCS surgeons. RESULTS BCS surgeons performed 432 of 675 laminoplasties. NBCS surgeons were primary in 243 surgeries, of which 187 were directly supervised by a BCS surgeon. BCS surgeons required significantly less time in surgery (98.0 ± 39.5 vs 108.1 ± 49.7 min; P < .01). BCS and NBCS surgeons had comparable perioperative complications rates, and preoperative-to-postoperative changes in JOA scores (2.9 ± 2.1 vs 3.1 ± 2.3; P = .40) and VAS (-1.5 ± 2.9 vs -1.4 ± 2.5; P = .96). Lordotic cervical alignment and ROM were maintained after operations by both groups. CONCLUSIONS Surgical outcomes such as functional recovery, complication rates, and cervical dynamics were comparable between the BCS and NBCS groups. Thus, posterior cervical decompression for CSM is safe and effective when performed by junior surgeons who have been trained and supervised by experienced spine surgeons.
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Affiliation(s)
- Narihito Nagoshi
- Department of Orthopedic Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Akio Iwanami
- Department of Orthopedic Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Koga Hospital Spine Center, Koga, Japan
| | - Norihiro Isogai
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Spine and Spinal Cord Center, International University of Health and Welfare (IUHW) Mita Hospital, Minato-ku, Tokyo, Japan
| | - Masayuki Ishikawa
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Spine and Spinal Cord Center, International University of Health and Welfare (IUHW) Mita Hospital, Minato-ku, Tokyo, Japan
- Department of Orthopedic Surgery, School of Medicine, International University of Health and Welfare (IUHW), Narita, Chiba, Japan
| | - Kenya Nojiri
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Department of Orthopedic Surgery, Isehara Kyodo Hospital, Isehara, Kanagawa, Japan
| | - Takashi Tsuji
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Department of Orthopedic Surgery, Fujita Health University, Toyoake, Mie, Japan
| | - Kenshi Daimon
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Department of Orthopedic Surgery, Ogikubo Hospital, Suginami, Tokyo, Japan
| | - Ayano Takeuchi
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Osahiko Tsuji
- Department of Orthopedic Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Eijiro Okada
- Department of Orthopedic Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Nobuyuki Fujita
- Department of Orthopedic Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Mitsuru Yagi
- Department of Orthopedic Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Kota Watanabe
- Department of Orthopedic Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Masaya Nakamura
- Department of Orthopedic Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Morio Matsumoto
- Department of Orthopedic Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Ken Ishii
- Department of Orthopedic Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
- Spine and Spinal Cord Center, International University of Health and Welfare (IUHW) Mita Hospital, Minato-ku, Tokyo, Japan
- Department of Orthopedic Surgery, School of Medicine, International University of Health and Welfare (IUHW), Narita, Chiba, Japan
| | - Junichi Yamane
- Keio Spine Research Group (KSRG), Tokyo, Japan
- National Hospital Organization Murayama Medical Center, Musashimurayama City, Tokyo, Japan
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Effect of Resident and Fellow Involvement in Adult Spinal Deformity Surgery. World Neurosurg 2019; 122:e759-e764. [DOI: 10.1016/j.wneu.2018.10.135] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 10/18/2018] [Accepted: 10/20/2018] [Indexed: 11/18/2022]
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Surgical training in spine surgery: safety and patient-rated outcome. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:807-816. [DOI: 10.1007/s00586-019-05883-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 01/11/2019] [Indexed: 10/27/2022]
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Fletcher ND, Marks MC, Asghar JK, Hwang SW, Sponseller PD, Newton PO. Development of Consensus Based Best Practice Guidelines for Perioperative Management of Blood Loss in Patients Undergoing Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis. Spine Deform 2019; 6:424-429. [PMID: 29886914 DOI: 10.1016/j.jspd.2018.01.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 01/03/2018] [Indexed: 11/17/2022]
Abstract
STUDY DESIGN Delphi process with multiple iterative rounds using a nominal group technique. OBJECTIVE The aim of this study was to use expert opinion to achieve consensus on various methods for minimizing blood loss in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). BACKGROUND DATA Perioperative blood loss management represents a critical component of safely performing PSF in children with AIS. Little consensus exists on ways to mitigate excessive blood loss after PSF. METHODS An expert panel composed of 21 pediatric spine surgeons was selected. Using the Delphi process and iterative rounds using a nominal group technique, participants in this panel were presented with a detailed literature review and asked to voice opinion collectively during three rounds of voting. Agreement >80% was considered consensus. Interventions without consensus were discussed and revised, if feasible. RESULTS Consensus was reached to support 21 best practice guideline measures for perioperative management of blood loss in patients undergoing PSF for AIS. Areas included preoperative assessment and preparation, intraoperative strategies to decrease blood loss, and postoperative transfusion indications. CONCLUSION We present a consensus-based best practice guideline consisting of 21 recommendations for strategies to minimize and manage blood loss during PSF. This can serve to reduce variability in practice in this area, help develop hospital specific protocols, and guide future research.
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Affiliation(s)
- Nicholas D Fletcher
- Emory University Department of Orthopaedics, 59 Executive Park South NE, Atlanta, GA 30329, USA.
| | - Michelle C Marks
- Emory University Department of Orthopaedics, 59 Executive Park South NE, Atlanta, GA 30329, USA
| | - Jahangir K Asghar
- Emory University Department of Orthopaedics, 59 Executive Park South NE, Atlanta, GA 30329, USA
| | - Steven W Hwang
- Emory University Department of Orthopaedics, 59 Executive Park South NE, Atlanta, GA 30329, USA
| | - Paul D Sponseller
- Emory University Department of Orthopaedics, 59 Executive Park South NE, Atlanta, GA 30329, USA
| | - Peter O Newton
- Emory University Department of Orthopaedics, 59 Executive Park South NE, Atlanta, GA 30329, USA
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Louie PK, Schairer WW, Haughom BD, Bell JA, Campbell KJ, Levine BR. Involvement of Residents Does Not Increase Postoperative Complications After Open Reduction Internal Fixation of Ankle Fractures: An Analysis of 3251 Cases. J Foot Ankle Surg 2018; 56:492-496. [PMID: 28245974 DOI: 10.1053/j.jfas.2017.01.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Indexed: 02/03/2023]
Abstract
Ankle fractures are common injuries frequently treated by foot and ankle surgeons. Therefore, it has become a core competency for orthopedic residency training. Surgical educators must balance the task of training residents with optimizing patient outcomes and minimizing morbidity and mortality. The present study aimed to determine the effect of resident involvement on the 30-day postoperative complication rates after open reduction and internal fixation of ankle fractures. A second objective of the present study was to determine the independent risk factors for complications after this procedure. We identified patients in the American College of Surgeons National Surgical Quality Improvement Program database who had undergone open reduction internal fixation for ankle fractures from 2005 to 2012. Propensity score matching was used to help account for a potential selection bias. We performed univariate and multivariate analyses to identify the independent risk factors associated with short-term postoperative complications. A total of 3251 open reduction internal fixation procedures for ankle fractures were identified, of which 959 (29.4%) had resident involvement. Univariate (2.82% versus 4.54%; p = .024) and multivariate (odds ratio 0.71; p = .75) analyses demonstrated that resident involvement did not increase short-term complication rates. The independent risk factors for complications after open reduction internal fixation of ankle fractures included insulin-dependent diabetes, increasing age, higher American Society of Anesthesiologists score, and longer operative times.
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Affiliation(s)
- Philip K Louie
- Orthopedist, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL.
| | - William W Schairer
- Orthopedist, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Bryan D Haughom
- Orthopedist, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Joshua A Bell
- Orthopedist, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Kevin J Campbell
- Orthopedist, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Brett R Levine
- Orthopedist, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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Seicean A, Kumar P, Seicean S, Neuhauser D, Selman WR, Bambakidis NC. Impact of Resident Involvement in Neurosurgery: An American College of Surgeons' National Surgical Quality Improvement Program Database Analysis of 33,977 Patients. Neurospine 2018; 15:54-65. [PMID: 29656619 PMCID: PMC5944634 DOI: 10.14245/ns.1836008.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 03/16/2018] [Accepted: 03/20/2018] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE There is conflicting and limited literature on the effect of intraoperative resident involvement on surgical outcomes. Our study assessed effects of resident involvement on outcomes in patients undergoing neurosurgery. METHODS We identified 33,977 adult neurosurgical cases from 374 hospitals in the 2006-2012 National Surgical Quality Improvement Program, a prospectively collected national database with established reproducibility and validity. Outcomes were compared according to resident involvement before and after 1:1 matching on procedure and perioperative risk factors. RESULTS Resident involvement was documented in 13,654 cases. We matched 10,170 resident-involved cases with 10,170 attending-alone. In the matched sample, resident involvement was associated with increased surgery duration (average, 34 minutes) and slight increases in odds for prolonged hospital stay (odds ratio, 1.2; 95% confidence interval [CI], 1.2-1.3) and complications (odds ratio, 1.2; 95% CI, 1.1-1.3) including infections (odds ratio, 1.4; 95% CI, 1.2-1.7). Increased risk for infections persisted after controlling for surgery duration (odds ratio, 1.3; 95% CI, 1.1-1.5). The majority of cases were spine surgeries, and resident involvement was not associated with morbidity or mortality for malignant tumor and aneurysm patients. Training level of residents was not associated with differences in outcomes. CONCLUSION Resident involvement was more common in sicker patients undergoing complex procedures, consistent with academic centers undertaking more complex cases. After controlling for patient and intraoperative characteristics, resident involvement in neurosurgical cases continued to be associated with longer surgical duration and slightly higher infection rates. Longer surgery duration did not account for differences in infection rates.
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Affiliation(s)
- Andreea Seicean
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA
| | - Prateek Kumar
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Sinziana Seicean
- Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Duncan Neuhauser
- Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, OH, USA
| | - Warren R. Selman
- Department of Neurosurgery, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Nicholas C. Bambakidis
- Department of Neurosurgery, University Hospitals Case Medical Center, Cleveland, OH, USA
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Abstract
STUDY DESIGN Retrospective study of prospectively collected data OBJECTIVE.: The aim of this study was to assess the impact of resident surgeon involvement on patient outcomes following posterior cervical fusion (PCF) surgery. SUMMARY OF BACKGROUND DATA Recently, there has been a significant uptrend in the number of PCF performed in the United States. Prior studies have investigated patient outcomes after cervical arthrodesis. Despite the heightened concern for patient safety and quality improvement, the data on the safety of resident participation in PCF is sparse. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was examined from 2005 to 2012. Current Procedural Terminology codes were used to query the database for adults (≥18 years) who underwent PCF. Multivariate logistic regression models were employed on data adjusted by propensity scores to determine whether resident involvement was an independent predictor for the outcomes of interest. RESULTS A total of 448 cases were assessed in NSQIP. Less than half of these cases involved residents (224, 43.1%). Resident involvement was found to be a significant predictor for blood transfusions [odds ratio (OR) = 1.7, confidence interval (CI) = 1.1-2.6, P = 0.010], length of stay of more than 5 days (OR = 1.6, CI = 1.0-2.6, P = 0.040), and operative time more than 4 hours (OR = 3.6, CI = 1.7-7.4, P = 0.0007). Other independent risk factors for prolonged length of stay included age 81 years or older versus 50 years or younger (OR = 4.7, CI = 1.7-12.6, P = 0.016) and diabetes (OR = 2.3, CI = 1.3-4.1, P = 0.006). In addition, multifusion was identified as a significant risk factor for extended operative time (OR = 1.8, CI = 1.1-2.9, P = 0.023). CONCLUSION The present study used a large, nationwide sample to assess the impact of resident involvement in PCF. Resident participation was not associated with mortality, but had a minimal association with morbidity. LEVEL OF EVIDENCE 3.
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Neuwirth AL, Stitzlein RN, Neuwirth MG, Kelz RK, Mehta S. Resident Participation in Fixation of Intertrochanteric Hip Fractures: Analysis of the NSQIP Database. J Bone Joint Surg Am 2018; 100:155-164. [PMID: 29342066 DOI: 10.2106/jbjs.16.01611] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Future generations of orthopaedic surgeons must continue to be trained in the surgical management of hip fractures. This study assesses the effect of resident participation on outcomes for the treatment of intertrochanteric hip fractures. METHODS The National Surgical Quality Improvement Program (NSQIP) database (2010 to 2013) was queried for intertrochanteric hip fractures (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM] code 820.21) treated with either extramedullary (Current Procedural Terminology [CPT] code 27244) or intramedullary (CPT code 27245) fixation. Demographic variables, including resident participation, as well as primary (death and serious morbidity) and secondary outcome variables were extracted for analysis. Univariate, propensity score-matched, and multivariate logistic regression analyses were performed to evaluate outcome variables. RESULTS Data on resident participation were available for 1,764 cases (21.0%). Univariate analyses for all intertrochanteric hip fractures demonstrated no significant difference in 30-day mortality (6.3% versus 7.8%; p = 0.264) or serious morbidity (44.9% versus 43.2%; p = 0.506) between the groups with and without resident participation. Multivariate and propensity score-matched analyses gave similar results. Resident involvement was associated with prolonged operating-room time, length of stay, and time to discharge when a prolonged case was defined as one above the 90th percentile for time parameters. CONCLUSIONS Resident participation was not associated with an increase in morbidity or mortality but was associated with an increase in time-related secondary outcome measures. While attending surgeon supervision is necessary, residents can and should be involved in the care of these patients without concern that resident involvement negatively impacts perioperative morbidity and mortality. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alexander L Neuwirth
- Departments of Orthopaedic Surgery (A.L.N., R.N.S., and S.M.) and General Surgery (M.G.N and R.K.K.), University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Russell N Stitzlein
- Departments of Orthopaedic Surgery (A.L.N., R.N.S., and S.M.) and General Surgery (M.G.N and R.K.K.), University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Madalyn G Neuwirth
- Departments of Orthopaedic Surgery (A.L.N., R.N.S., and S.M.) and General Surgery (M.G.N and R.K.K.), University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Rachel K Kelz
- Departments of Orthopaedic Surgery (A.L.N., R.N.S., and S.M.) and General Surgery (M.G.N and R.K.K.), University of Pennsylvania Health System, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Samir Mehta
- Departments of Orthopaedic Surgery (A.L.N., R.N.S., and S.M.) and General Surgery (M.G.N and R.K.K.), University of Pennsylvania Health System, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Gross CE, Chang D, Adams SB, Parekh SG, Bohnen JD. Surgical resident involvement in foot and ankle surgery. Foot Ankle Surg 2017; 23:261-267. [PMID: 29202985 DOI: 10.1016/j.fas.2016.08.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 05/19/2016] [Accepted: 08/01/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Surgical resident participation in the operating room is necessary for education and progression toward safe and independent practice. However, the impact of resident involvement on patient outcomes in foot and ankle surgery is unknown. METHODS The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database (2005-2012) was used to identify common foot and ankle procedures (by Current Procedural Taxonomy (CPT) code) performed by orthopedic surgeons. Resident participation was determined using the NSQIP-collected variable 'pgy'; cases missing the pgy variable were excluded. Multivariate regression models were constructed to determine an association between resident involvement and 30-day morbidity (total, medical, and surgical complications) and 30-day mortality, when controlling for patient demographics, comorbidities, American Society for Anesthesiologist (ASA) status, body mass index (BMI), and smoking status. RESULTS A total of 13,685 cases were analyzed for 24 common foot and ankle operations. Overall mortality rate was 3.60%. Overall complication rate was 16.9%; 10.9% had medical and 8.3% had surgical complications. Residents were involved in 55.6% of cases. In unadjusted analyses, resident cases were less likely to be emergent, but were performed on more complicated patients (i.e. higher comorbidity burden, higher ASA scores). Resident cases had increased total morbidity (18.8% vs. 14.6%, p<0.001), medical complications (12.5% vs. 9.0%, p<0.001), and surgical complications (8.7% vs. 7.7%, p=0.03), but similar mortality frequency (3.8% vs. 3.3%, p=0.2). In multivariable analyses, resident cases did not correlate with 30-day mortality, 30-day total morbidity, or 30-day surgical complications; resident cases were, however, associated with increased medical complications [Odds Ratio (OR) 1.18 (95% Confidence Interval (CI) 1.02-1.37, p=0.03)] and longer length of stay [Coeff 2.38 (1.68-3.09), p<0.001]. Subgroup analyses of orthopedic-only cases demonstrated no statistical association between resident involvement and mortality, total morbidity, or medical complications; a decrease in surgical complications was observed for open reduction internal fixation cases [OR 0.23 (0.06-0.82), p=0.02]. CONCLUSIONS Resident involvement in foot and ankle surgery is not associated with changes in 30-day mortality, 30-day total morbidity, or 30-day surgical complication rates. Residents operate on more medically complex patients who experience higher medical complication rates and longer postoperative length of stay; however, the cause and directionality of this relationship remains to be determined. Efforts to improve the quality of foot and ankle surgery with resident involvement should target reductions in post-operative medical complications. LEVEL OF EVIDENCE Prognostic study, Level II.
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Affiliation(s)
- Christopher E Gross
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, SC, United States.
| | - David Chang
- Department of Surgery, Massachusetts General Hospital, Boston, MA, United States
| | - Samuel B Adams
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, United States
| | - Selene G Parekh
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, United States; Fuqua School of Business, Duke University, Durham, NC, United States
| | - Jordan D Bohnen
- Department of Surgery, Massachusetts General Hospital, Boston, MA, United States
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Baker AB, Ong AA, O'Connell BP, Sokohl AD, Clinkscales WB, Meyer TA. Impact of resident involvement in outpatient otolaryngology procedures: An analysis of 17,647 cases. Laryngoscope 2017; 127:2026-2032. [PMID: 28543359 DOI: 10.1002/lary.26645] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 03/17/2017] [Accepted: 03/27/2017] [Indexed: 12/21/2022]
Abstract
OBJECTIVE This study examines the impact of resident physician participation on postoperative outcomes in outpatient otolaryngologic surgery. STUDY DESIGN Retrospective cohort. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was queried for outpatient otolaryngologic procedures performed on adult patients. Cases were analyzed with the following cohorts: attending with resident or attending without resident. Outcomes included complications, readmission, reoperation, and operative time. RESULTS A total of 17,647 cases were analyzed, with 13,123 patients in the attending without resident cohort and 4,524 patients in the attending with resident cohort. The majority of patients were female (58.7%) and white (88.0%). The average age was 44 (range 16-89) years, and average body mass index was 29.0 ± 7.3 kg/m2 . Total relative value units were higher in the attending with resident group 14.6 ± 12.0 compared with 10.2 ± 8.3 in the attending without resident group (P < 0.01). Univariate analysis revealed that resident participation increased complication rate (2.0% vs. 1.4%, P < 0.01) and operative time (108 ± 98 minutes vs. 60 ± 55 minutes, P < 0.01). There were no differences in readmissions (P = 0.35), reoperations (P > 0.05), or death rates (P = 0.32) between groups. Multivariate regression analysis, however, revealed that resident participation did not increase the rate of any complication, and that operative time was the only significantly impacted variable (P < 0.01). CONCLUSION Resident surgical training remains a vital component of the current health care system. Previous research has shown that, despite increased operative time, resident participation does not significantly impact complication rates for otolaryngology procedures. This study confirms these findings in the outpatient setting, thus reassuring both the surgeon and patients that resident participation does not impact procedural safety. LEVEL OF EVIDENCE 4. Laryngoscope, 127:2026-2032, 2017.
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Affiliation(s)
- Andrew B Baker
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Adrian A Ong
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Brendan P O'Connell
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University, Nashville, Tennessee, U.S.A
| | - Alexander D Sokohl
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - William B Clinkscales
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Ted A Meyer
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
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Lonner BS, Toombs CS, Paul JC, Shah SA, Shufflebarger HL, Flynn JM, Newton PO. Resource Utilization in Adolescent Idiopathic Scoliosis Surgery: Is There Opportunity for Standardization? Spine Deform 2017; 5:166-171. [PMID: 28449959 DOI: 10.1016/j.jspd.2017.01.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 11/23/2016] [Accepted: 01/03/2017] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Recent healthcare reforms have raised the importance of cost and value in the management of disease. Value is a function of benefit and cost. Understanding variability in resources utilized by individual surgeons to achieve similar outcomes may provide an opportunity for cutting costs though greater standardization. The purpose of this study is to evaluate differences in use of implants and hospital resources among surgeons performing adolescent idiopathic scoliosis (AIS) surgery. METHODS A multicenter prospective AIS operative database was queried. Patients were matched for Lenke curve type and curve magnitude, resulting in 5 surgeons and 35 matched groups (N = 175). Mean patient age was 14.9 years and curve magnitude 50°. Parameters of interest were compared between surgeons via ANOVA and Bonferroni pairwise comparison. RESULTS There was no significant difference in percentage curve correction or levels fused between surgeons. Significant differences between surgeons were found for percentage posterior approach, operative time, length of stay (LOS), estimated blood loss (EBL), cell saver transfused, rod material, screw density, number of screws, use of antifibrinolytics, and cessation of intravenous analgesics. Despite differences in EBL and cell saver transfused, there were no differences in allogenic blood (blood bank) use. CONCLUSION Significant variability in resource utilization was noted between surgeons performing AIS operations, although radiographic results were uniform. Standardization of resource utilization and cost containment opportunities include implant usage, rod material, LOS, and transition to oral analgesics, as these factors are the largest contributors to cost in AIS surgery.
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Affiliation(s)
- Baron S Lonner
- Department of Orthopaedic Surgery, Mount Sinai-Beth Israel Medical Center, Scoliosis and Spine Associates, 820 Second Avenue, New York, NY 10017, USA.
| | - Courtney S Toombs
- New York University School of Medicine, Scoliosis and Spine Associates, 820 Second Avenue, New York, NY 10017, USA
| | - Justin C Paul
- Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, Scoliosis and Spine Associates, 820 Second Avenue, New York, NY 10017, USA
| | - Suken A Shah
- Department of Orthopaedic Surgery, AI Du Pont Hospital, Nemours Children's Clinic - Wilmington of the Nemours Foundation, 1600 Rockland Road, Wilmington, DE 19803, USA
| | - Harry L Shufflebarger
- Department of Orthopaedic Surgery, Miami Children's Hospital, Nicklaus Children's Orthopedic Spine Center, 3100 SW 62 Avenue NE Wing #108, Miami, FL 33155, USA
| | - John M Flynn
- Department of Orthopaedic Surgery, The Children's Hospital of Philadelphia, Division of Orthopedic Surgery, 2nd Floor Wood Building, 34th St. & Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Peter O Newton
- Department of Orthopaedic Surgery, Rady Children's Hospital, Pediatric Orthopedic & Scoliosis Ctr, 3030 Children's Way #410, San Diego, CA 92123, USA
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Joseph JR, Smith BW, Park P. Variability in Standard Outcomes of Posterior Lumbar Fusion Determined by National Databases. World Neurosurg 2016; 97:236-240. [PMID: 27742512 DOI: 10.1016/j.wneu.2016.09.117] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 09/27/2016] [Accepted: 09/29/2016] [Indexed: 12/21/2022]
Abstract
OBJECTIVE National databases are used with increasing frequency in spine surgery literature to evaluate patient outcomes. The differences between individual databases in relationship to outcomes of lumbar fusion are not known. We evaluated the variability in standard outcomes of posterior lumbar fusion between the University HealthSystem Consortium (UHC) database and the Healthcare Cost and Utilization Project National Inpatient Sample (NIS). METHODS NIS and UHC databases were queried for all posterior lumbar fusions (International Classification of Diseases, Ninth Revision code 81.07) performed in 2012. Patient demographics, comorbidities (including obesity), length of stay (LOS), in-hospital mortality, and complications such as urinary tract infection, deep venous thrombosis, pulmonary embolism, myocardial infarction, durotomy, and surgical site infection were collected using specific International Classification of Diseases, Ninth Revision codes. RESULTS Analysis included 21,470 patients from the NIS database and 14,898 patients from the UHC database. Demographic data were not significantly different between databases. Obesity was more prevalent in UHC (P = 0.001). Mean LOS was 3.8 days in NIS and 4.55 in UHC (P < 0.0001). Complications were significantly higher in UHC, including urinary tract infection, deep venous thrombosis, pulmonary embolism, myocardial infarction, surgical site infection, and durotomy. In-hospital mortality was similar between databases. CONCLUSIONS NIS and UHC databases had similar demographic patient populations undergoing posterior lumbar fusion. However, the UHC database reported significantly higher complication rate and longer LOS. This difference may reflect academic institutions treating higher-risk patients; however, a definitive reason for the variability between databases is unknown. The inability to precisely determine the basis of the variability between databases highlights the limitations of using administrative databases for spinal outcome analysis.
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Affiliation(s)
- Jacob R Joseph
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Brandon W Smith
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA.
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Impact of Resident Involvement on Morbidity in Adult Patients Undergoing Fusion for Spinal Deformity. Spine (Phila Pa 1976) 2016; 41:1296-1302. [PMID: 26909839 DOI: 10.1097/brs.0000000000001522] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective study of prospectively collected data. OBJECTIVE The aim of this study was to determine whether patients undergoing spinal deformity surgery with resident involvement are at an increased risk of morbidity. SUMMARY OF BACKGROUND DATA Resident involvement has been investigated in other orthopedic procedures but has not been studied in adult spinal deformity surgery. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) is a large multicenter clinical registry that prospectively collects preoperative risk factors, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes from about 400 hospitals nationwide. Current procedural terminology (CPT) codes were used to query the database for adults who underwent fusion for spinal deformity between 2005 and 2012. Patients were separated into propensity score matched groups of those with and without resident involvement. Univariate analysis and multivariate logistic regression were used to analyze the effect of resident involvement on the incidence of postoperative morbidity and other surgical outcomes. RESULTS Resident involvement was an independent predictor of overall morbidity [odds ratio (OR) 2.2, P < 0.0001], wound complication (OR 2.5, P = 0.0252), intra-/postoperative transfusion (OR 2.3, P < 0.0001), and length of stay > 5 days (OR 2.0, P < 0.0001). However, resident involvement was not an independent predictor for other complications, such as mortality. CONCLUSION Resident participation was associated with significantly longer operative times. As a result, higher rate of certain morbidity, but not mortality, was found, specifically for complications that have been previously associated with long operative duration. LEVEL OF EVIDENCE 3.
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Perioperative Outcome in Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis: A Prospective Study Comparing Single Versus Two Attending Surgeons Strategy. Spine (Phila Pa 1976) 2016; 41:E694-E699. [PMID: 26656053 DOI: 10.1097/brs.0000000000001349] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective study. OBJECTIVE To evaluate the perioperative outcome of posterior spinal fusion in adolescent idiopathic scoliosis (AIS) patients comparing a single attending surgeon strategy (G1) versus a dual attending surgeon strategy (G2). SUMMARY OF BACKGROUND DATA The complication rate for surgical correction in AIS is significant. There are no prospective studies that investigate dual attending surgeon strategy for posterior spinal fusion in AIS. METHODS A total of 60 patients (30 patients in each arm) were recruited. The patients were comparable for age, gender, Lenke classification, major Cobb angle magnitude, and number of fusion levels. The anesthetic, surgical, and postoperative protocol was standardized. The outcome measures included the operative duration, blood loss, postoperative hemoglobin, need for transfusion, morphine usage, duration of hospital stay, intraoperative lactate levels, and pH. The timing of the operation at six critical stages of the operation was recorded. RESULTS The mean operative time for G2 was 173.6 ± 27.0 minutes versus 248.0 ± 49.9 minutes in G1 (P < 0.000). Mean blood loss in G2 was 0.92 ± 0.4 L and 1.25 ± 0.6 L in G1 (P < 0.05). None of the patients in G2 required any allogenic transfusion. Four patients in G1 (13.3%) required allogenic blood product transfusion. The day 2 postoperative hemoglobin levels in both groups were similar, but this was taken after blood product transfusion in G1. The amount of morphine usage was 20.4 ± 11.5 mg in G2 and 42.5 ± 24.0 mg in G1 (P < 0.000). G2 patients had a shorter hospital stay. One patient in G1 had superficial wound infection. G2 was faster than G1 during exposure, instrumentation, facetectomy, and bone grafting. CONCLUSION The involvement of two attending surgeons significantly reduced operative time, blood loss, need for allogenic blood transfusion, patient-controlled analgesia morphine requirement and led to faster patient recovery during the perioperative period. LEVEL OF EVIDENCE 2.
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Mac-Thiong JM, Asghar J, Parent S, Shufflebarger HL, Samdani A, Labelle H. Posterior convex release and interbody fusion for thoracic scoliosis: technical note. J Neurosurg Spine 2016; 25:357-65. [PMID: 27058500 DOI: 10.3171/2016.2.spine15557] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Anterior release and fusion is sometimes required in pediatric patients with thoracic scoliosis. Typically, a formal anterior approach is performed through open thoracotomy or video-assisted thoracoscopic surgery. The authors recently developed a technique for anterior release and fusion in thoracic scoliosis referred to as "posterior convex release and interbody fusion" (PCRIF). This technique is performed via the posterior-only approach typically used for posterior instrumentation and fusion and thus avoids a formal anterior approach. In this article the authors describe the technique and its use in 9 patients-to prevent a crankshaft phenomenon in 3 patients and to optimize the correction in 6 patients with a severe thoracic curve showing poor reducibility. After Ponte osteotomies at the levels requiring anterior release and fusion, intervertebral discs are approached from the convex side of the scoliosis. The annulus on the convex side of the scoliosis is incised from the lateral border of the pedicle to the lateral annulus while visualizing and protecting the pleura and spinal cord. The annulus in contact with the pleura and the anterior longitudinal ligament are removed before completing the discectomies and preparing the endplates. The PCRIF was performed at 3 levels in 4 patients and at 4 levels in 5 patients. Mean correction of the main thoracic curve, blood loss, and length of stay were 74.9%, 1290 ml, and 7.6 days, respectively. No neurological deficit, implant failure, or pseudarthrosis was observed at the last follow-up. Two patients had pleural effusion postoperatively, with 1 of them requiring placement of a chest tube. One patient had pulmonary edema secondary to fluid overload, while another patient underwent reoperation for a deep wound infection 3 weeks after the initial surgery. The technique is primarily indicated in skeletally immature patients with open triradiate cartilage and/or severe scoliosis. It can be particularly useful if there is significant vertebral rotation because access to the disc and anterior longitudinal ligament from the convex side will become safer. The PCRIF is an alternative to the formal anterior approach and does not require repositioning between the anterior and posterior stages, which prolongs the surgery and can be associated with an increased complication rate. The procedure can be done in the presence of preexisting pulmonary morbidity such as pleural adhesions and decreased pulmonary function because it does not require mobilization of the lung or single-lung ventilation. However, PCRIF can still be associated with pulmonary complications such as a pleural effusion, and care should be taken to avoid iatrogenic injury to the pleura. Placement of a deep wound drain at the level of the PCRIF is strongly recommended if postoperative bleeding is anticipated, to decrease the risk of pleural effusion.
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Affiliation(s)
- Jean-Marc Mac-Thiong
- Department of Surgery, University of Montreal;,Department of Surgery, CHU Sainte-Justine;,Department of Surgery, Hôpital du Sacré-Coeur, Montreal, Quebec, Canada
| | - Jahangir Asghar
- Center for Spinal Disorders, Miami Children's Hospital, Miami, Florida; and
| | - Stefan Parent
- Department of Surgery, University of Montreal;,Department of Surgery, CHU Sainte-Justine;,Department of Surgery, Hôpital du Sacré-Coeur, Montreal, Quebec, Canada
| | | | - Amer Samdani
- Department of Surgery, Shriner's Hospital, Philadelphia, Pennsylvania
| | - Hubert Labelle
- Department of Surgery, University of Montreal;,Department of Surgery, CHU Sainte-Justine
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Cvetanovich GL, Schairer WW, Haughom BD, Nicholson GP, Romeo AA. Does resident involvement have an impact on postoperative complications after total shoulder arthroplasty? An analysis of 1382 cases. J Shoulder Elbow Surg 2015; 24:1567-73. [PMID: 25953488 DOI: 10.1016/j.jse.2015.03.023] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 03/11/2015] [Accepted: 03/18/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND The impact of resident involvement on total shoulder arthroplasty (TSA) complication rate is unknown. The purpose of this study was to assess whether resident involvement in TSA is associated with 30-day complication rates. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was searched for all patients who underwent TSA between 2005 and 2012. Data were extracted for patient preoperative demographics, intraoperative variables, resident involvement in surgery, and 30-day postoperative complications. Resident and nonresident cases were grouped by a matched propensity score analysis. Univariate and multivariate analysis was performed to assess the effect of resident involvement on postoperative complications. RESULTS We analyzed 1382 patients who underwent primary TSA, with matched groups of 691 with and 691 without resident involvement. The overall rate of 30-day complications was 2.60% in TSAs in which a resident was involved compared with 3.91% when no resident was involved (P = .173). Operative time and hospital stay were shorter in cases in which a resident was present (P = .002 and P < .001, respectively). Independent risk factors significantly associated with TSA complications identified by multivariate regression were higher patient age, higher American Society of Anesthesiologists classification, congestive heart failure, insulin-dependent diabetes, and peripheral vascular disease. CONCLUSION Resident involvement in TSA procedures is not a risk factor for 30-day complications. Patient factors including increased age, diabetes, and cardiac disease are risk factors for TSA complications. This information can be used in preoperative counseling to reassure patients about safety of resident involvement in TSA and to optimize patient comorbidities before surgery.
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Affiliation(s)
- Gregory L Cvetanovich
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.
| | - William W Schairer
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Bryan D Haughom
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Gregory P Nicholson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Anthony A Romeo
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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Durkin MJ, Dicks KV, Baker AW, Moehring RW, Chen LF, Sexton DJ, Lewis SS, Anderson DJ. Postoperative infection in spine surgery: does the month matter? J Neurosurg Spine 2015; 23:128-34. [PMID: 25860519 DOI: 10.3171/2014.10.spine14559] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECT The relationship between time of year and surgical site infection (SSI) following neurosurgical procedures is poorly understood. Authors of previous reports have demonstrated that rates of SSI following neurosurgical procedures performed during the summer months were higher compared with rates during other seasons. It is unclear, however, if this difference was related to climatological changes or inexperienced medical trainees (the July effect). The aim of this study was to evaluate for seasonal variation of SSI following spine surgery in a network of nonteaching community hospitals. METHODS The authors analyzed 6 years of prospectively collected surveillance data (January 1, 2007, to December 31, 2012) from all laminectomies and spinal fusions from 20 hospitals in the Duke Infection Control Outreach Network of community hospitals. Surgical site infections were defined using National Healthcare Safety Network criteria and identified using standardized methods across study hospitals. Regression models were then constructed using Poisson distribution to evaluate for seasonal trends by month. Each analysis was first performed for all SSIs and then for SSIs caused by specific organisms or classes of organisms. Categorical analysis was performed using two separate definitions of summer: June through September (definition 1), and July through September (definition 2). The prevalence rate of SSIs during the summer was compared with the prevalence rate during the remainder of the year by calculating prevalence rate ratios and 95% confidence intervals. RESULTS The authors identified 642 SSIs following 57,559 neurosurgical procedures (overall prevalence rate = 1.11/100 procedures); 215 occurred following 24,466 laminectomies (prevalence rate = 0.88/100 procedures), and 427 following 33,093 spinal fusions (prevalence rate = 1.29/100 procedures). Common causes of SSI were Staphylococcus aureus (n = 380; 59%), coagulase-negative staphylococci (n = 90; 14%), and Escherichia coli (n = 41; 6.4%). Poisson regression models demonstrated increases in the rates of SSI during each of the summer months for all SSIs and SSIs due to gram-positive cocci, S. aureus, and methicillin-sensitive S. aureus. Categorical analysis confirmed that the rate of SSI during the 4-month summer period was higher than the rate during the remainder of the year, regardless of which definition for summer was used (definition 1, p = 0.008; definition 2, p = 0.003). Similarly, the rates of SSI due to grampositive cocci and S. aureus were higher during the summer months than the remainder of the year regardless of which definition of summer was used. However, the rate of SSI due to gram-negative bacilli was not. CONCLUSIONS The rate of SSI following fusion or spinal laminectomy/laminoplasty was higher during the summer in this network of community hospitals. The increase appears to be related to increases in SSIs caused by gram-positive cocci and, more specifically, S. aureus. Given the nonteaching nature of these hospitals, the findings demonstrate that increases in the rate of SSI during the summer are more likely related to ecological and/or environmental factors than the July effect.
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Affiliation(s)
- Michael J Durkin
- Department of Medicine, Division of Infectious Diseases, Duke University Medical Center;,Duke Infection Control Outreach Network; and
| | - Kristen V Dicks
- Department of Medicine, Division of Infectious Diseases, Duke University Medical Center;,Duke Infection Control Outreach Network; and
| | - Arthur W Baker
- Department of Medicine, Division of Infectious Diseases, Duke University Medical Center;,Duke Infection Control Outreach Network; and
| | - Rebekah W Moehring
- Department of Medicine, Division of Infectious Diseases, Duke University Medical Center;,Duke Infection Control Outreach Network; and.,Durham VA Medical Center, Durham, North Carolina
| | - Luke F Chen
- Department of Medicine, Division of Infectious Diseases, Duke University Medical Center;,Duke Infection Control Outreach Network; and
| | - Daniel J Sexton
- Department of Medicine, Division of Infectious Diseases, Duke University Medical Center;,Duke Infection Control Outreach Network; and
| | - Sarah S Lewis
- Department of Medicine, Division of Infectious Diseases, Duke University Medical Center;,Duke Infection Control Outreach Network; and
| | - Deverick J Anderson
- Department of Medicine, Division of Infectious Diseases, Duke University Medical Center;,Duke Infection Control Outreach Network; and
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Basques BA, Bohl DD, Golinvaux NS, Smith BG, Grauer JN. Patient factors are associated with poor short-term outcomes after posterior fusion for adolescent idiopathic scoliosis. Clin Orthop Relat Res 2015; 473:286-94. [PMID: 25201091 PMCID: PMC4390920 DOI: 10.1007/s11999-014-3911-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Accepted: 08/19/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Posterior spinal fusion (PSF) is commonly performed for patients with adolescent idiopathic scoliosis (AIS). Identifying factors associated with perioperative morbidity and PSF may lead to strategies for reducing the frequency of adverse events (AEs) in patients and total hospital costs. QUESTIONS/PURPOSES What is the frequency of and what factors are associated with postoperative: (1) AEs, (2) extended length of stay (LOS), and (3) readmission in patients with AIS undergoing PSF? PATIENTS AND METHODS Patients, aged 11 to 18 years, who underwent PSF for AIS during 2012, were identified from the American College of Surgeons National Surgical Quality Improvement Program® (ACS NSQIP®) Pediatric database. Patient were assessed for characteristics associated with AEs, extended LOS (defined as more than 6 days), and hospital readmission using multivariate logistic regression. Individual AEs captured in the database were grouped into two categories, "any adverse event" (AAE) and "severe adverse events" (SAEs) for analysis. A total of 733 patients met inclusion criteria. RESULTS Twenty-seven patients (3.7%) had AAE and 19 patients (2.6%) had SAEs. Both AAE and SAEs were associated with BMI-for-age ninety-fifth percentile or greater (AAE: odds ratio [OR], 3.31; 95% CI, 1.43-7.65; p=0.005. SAE: OR, 3.46; 95% CI, 1.32-9.09; p=0.012). Extended LOS occurred for 60 patients (8.2%) and was associated with greater than 13 levels instrumented (OR, 2.00; 95% CI, 1.11-3.61; p=0.021) and operative time of 365 minutes or more (OR, 2.57; 95% CI, 1.39-4.76; p=0.003). Readmission occurred for 11 patients (1.5%), most often for surgical site infection, and was associated with the occurrence of any complication during the initial hospital stay (OR, 180.44; 95% CI, 35.47-917.97; p<0.001). CONCLUSIONS Further research on prevention and management of obesity and surgical site infections may reduce perioperative morbidity for patients with AIS undergoing PSF. LEVEL OF EVIDENCE Level III, prognostic study. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Bryce A. Basques
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, 800 Howard Avenue, New Haven, CT 06510 USA
| | - Daniel D. Bohl
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, 800 Howard Avenue, New Haven, CT 06510 USA
| | - Nicholas S. Golinvaux
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, 800 Howard Avenue, New Haven, CT 06510 USA
| | - Brian G. Smith
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, 800 Howard Avenue, New Haven, CT 06510 USA
| | - Jonathan N. Grauer
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, 800 Howard Avenue, New Haven, CT 06510 USA
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Haughom BD, Schairer WW, Hellman MD, Yi PH, Levine BR. Resident involvement does not influence complication after total hip arthroplasty: an analysis of 13,109 cases. J Arthroplasty 2014; 29:1919-24. [PMID: 24997650 DOI: 10.1016/j.arth.2014.06.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 05/05/2014] [Accepted: 06/03/2014] [Indexed: 02/01/2023] Open
Abstract
Our study aimed to determine the impact of resident involvement on the 30-day postoperative complication rates following primary total hip arthroplasty (THA). Using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, 13,109 primary THAs were identified, of which 3462 (26.4%) had resident involvement. Neither univariate (4.45% vs 4.52%, P = 0.86) nor multivariate (OR 1.04, P = 0.75) analyses demonstrated an increased complication rate with resident involvement following THA. We did find, however, that increased operative time, comorbidities, age, obesity, prior history of stroke and/or cardiac surgery were all independent risk factors for short-term complication. Our findings suggest that resident involvement does not increase 30-day complication rates following primary THA.
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Affiliation(s)
- Bryan D Haughom
- Department of Orthopaedic Surgery, Rush University, Chicago, Illinois
| | - William W Schairer
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Michael D Hellman
- Department of Orthopaedic Surgery, Rush University, Chicago, Illinois
| | - Paul H Yi
- Boston University School of Medicine, Boston, Massachusetts
| | - Brett R Levine
- Department of Orthopaedic Surgery, Rush University, Chicago, Illinois
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Edelstein AI, Lovecchio FC, Saha S, Hsu WK, Kim JYS. Impact of Resident Involvement on Orthopaedic Surgery Outcomes: An Analysis of 30,628 Patients from the American College of Surgeons National Surgical Quality Improvement Program Database. J Bone Joint Surg Am 2014; 96:e131. [PMID: 25100784 DOI: 10.2106/jbjs.m.00660] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Operative procedural training is a key component of orthopaedic surgery residency. The influence of intraoperative resident participation on the outcomes of surgery has not been studied extensively using large, population-based databases. METHODS We identified 30,628 patients who underwent orthopaedic procedures from the 2011 American College of Surgeons National Surgical Quality Improvement Program. Outcomes as measured by perioperative complications, readmission rates, and mortality within thirty days were compared for cases with and without intraoperative resident involvement. RESULTS Logistic regression with propensity score analysis revealed that intraoperative resident participation was associated with decreased rates of overall complications (odds ratio, 0.717 [95% confidence interval, 0.657 to 0.782]), medical complications (odds ratio, 0.723 [95% confidence interval, 0.661 to 0.790]), and mortality (odds ratio, 0.638 [95% confidence interval, 0.427 to 0.951]). Resident presence in the operating room was not predictive of wound complications (odds ratio, 0.831 [95% confidence interval, 0.656 to 1.053]), readmission (odds ratio, 0.962 [95% confidence interval, 0.830 to 1.116]), or reoperation (odds ratio, 0.938 [95% confidence interval, 0.758 to 1.161]). A second analysis by propensity score stratification into quintiles grouped by similar probability of intraoperative resident presence showed resident involvement to correlate with decreased rates of overall and medical complications in three quintiles, but increased rates of overall and medical complications in one quintile. All other outcomes were equivalent across quintiles. CONCLUSIONS Orthopaedic resident involvement during surgical procedures is associated with lower risk of perioperative complications and mortality in the National Surgical Quality Improvement Program database. The results support resident participation in the operative care of orthopaedic patients. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Adam I Edelstein
- Departments of Orthopaedic Surgery (A.I.E. and W.K.H.) and Surgery (F.C.L., S.S., and J.Y.S.K.), Northwestern University, Feinberg School of Medicine, 675 North Saint Clair Street, Galter Suite 19-250, Chicago, IL 60611. E-mail address for J.Y.S. Kim:
| | - Francis C Lovecchio
- Departments of Orthopaedic Surgery (A.I.E. and W.K.H.) and Surgery (F.C.L., S.S., and J.Y.S.K.), Northwestern University, Feinberg School of Medicine, 675 North Saint Clair Street, Galter Suite 19-250, Chicago, IL 60611. E-mail address for J.Y.S. Kim:
| | - Sujata Saha
- Departments of Orthopaedic Surgery (A.I.E. and W.K.H.) and Surgery (F.C.L., S.S., and J.Y.S.K.), Northwestern University, Feinberg School of Medicine, 675 North Saint Clair Street, Galter Suite 19-250, Chicago, IL 60611. E-mail address for J.Y.S. Kim:
| | - Wellington K Hsu
- Departments of Orthopaedic Surgery (A.I.E. and W.K.H.) and Surgery (F.C.L., S.S., and J.Y.S.K.), Northwestern University, Feinberg School of Medicine, 675 North Saint Clair Street, Galter Suite 19-250, Chicago, IL 60611. E-mail address for J.Y.S. Kim:
| | - John Y S Kim
- Departments of Orthopaedic Surgery (A.I.E. and W.K.H.) and Surgery (F.C.L., S.S., and J.Y.S.K.), Northwestern University, Feinberg School of Medicine, 675 North Saint Clair Street, Galter Suite 19-250, Chicago, IL 60611. E-mail address for J.Y.S. Kim:
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Haughom BD, Schairer WW, Hellman MD, Yi PH, Levine BR. Does resident involvement impact post-operative complications following primary total knee arthroplasty? An analysis of 24,529 cases. J Arthroplasty 2014; 29:1468-1472.e2. [PMID: 24726182 DOI: 10.1016/j.arth.2014.02.036] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 02/16/2014] [Accepted: 02/28/2014] [Indexed: 02/01/2023] Open
Abstract
Little is known about the impact of resident involvement on complication rates following total knee arthroplasty (TKA). The goal of our study was to determine the impact of resident involvement on complications following primary TKA. Using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database (2005-2012) we identified 24,529 patients who underwent primary TKA. Of these, 5960 (24.3%) had a resident involved in a primary TKA. Using a multivariate logistic regression which incorporated propensity score adjustment, no differences were seen in morbidity and mortality following those cases with resident involvement (OR: 1.15, P = 0.129). In the first large scale, comprehensive analysis of resident impact on short-term morbidity and mortality, no increase in complications was observed with resident involvement in primary TKA.
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Affiliation(s)
- Bryan D Haughom
- Department of Orthopaedic Surgery, Rush University, Chicago, Illinois
| | - William W Schairer
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Michael D Hellman
- Department of Orthopaedic Surgery, Rush University, Chicago, Illinois
| | - Paul H Yi
- Boston University School of Medicine, Boston, Massachusetts
| | - Brett R Levine
- Department of Orthopaedic Surgery, Rush University, Chicago, Illinois
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Pugely AJ, Gao Y, Martin CT, Callaghan JJ, Weinstein SL, Marsh JL. The effect of resident participation on short-term outcomes after orthopaedic surgery. Clin Orthop Relat Res 2014; 472:2290-300. [PMID: 24658902 PMCID: PMC4048420 DOI: 10.1007/s11999-014-3567-0] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 03/03/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND The influence of resident involvement on short-term outcomes after orthopaedic surgery is mostly unknown. QUESTIONS/PURPOSES The purposes of our study were to examine the effects of resident involvement in surgical cases on short-term morbidity, mortality, operating time, hospital length of stay, and reoperation rate and to analyze these parameters by level of training. METHODS The 2005–2011 American College of Surgeons National Surgical Quality Improvement Program data set was queried using Current Procedural Terminology codes for 66,817 cases across six orthopaedic procedural domains: 28,686 primary total joint arthroplasties (TJAs), 2412 revision TJAs, 16,832 basic and 5916 advanced arthroscopies, 8221 lower extremity traumas, and 4750 spine arthrodeses (fusions). Bivariate and multivariate logistic regression and propensity scores were used to build models of risk adjustment. We compared the morbidity and mortality rates, length of operating time, hospital length of stay, and reoperation rate for cases with or without resident involvement. For cases with resident participation, we analyzed the same parameters by training level. RESULTS Resident participation was associated with higher morbidity in TJAs (odds ratio [OR], 1.6; range, 1.4–1.9), lower extremity trauma (OR, 1.3; range, 1.2–1.5), and fusion (OR, 1.4; range, 1.2–1.7) after adjustment. However, resident involvement was not associated with increased mortality. Operative time was greater (all p < 0.001) with resident involvement in all procedural domains. Longer hospital length of stay was associated with resident participation in lower extremity trauma (p < 0.001) and fusion cases (p = 0.003), but resident participation did not affect length of stay in other domains. Resident involvement was associated with greater 30-day reoperation rates for cases of lower extremity trauma (p = 0.041) and fusion (p < 0.001). Level of resident training did not consistently influence surgical outcomes. CONCLUSIONS Results of our study suggest resident involvement in surgical procedures is not associated with increased short-term major morbidity and mortality after select cases in orthopaedic surgery. Findings of longer operating times and differences in minor morbidity should lead to future initiatives to provide resident surgical skills training and improve perioperative efficiency in the academic setting. LEVEL OF EVIDENCE Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Andrew J. Pugely
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 01008 JPP, Iowa City, IA 52242 USA
| | - Yubo Gao
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 01008 JPP, Iowa City, IA 52242 USA
| | - Christopher T. Martin
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 01008 JPP, Iowa City, IA 52242 USA
| | - John J. Callaghan
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 01008 JPP, Iowa City, IA 52242 USA
| | - Stuart L. Weinstein
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 01008 JPP, Iowa City, IA 52242 USA
| | - J. Lawrence Marsh
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 01008 JPP, Iowa City, IA 52242 USA
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Stienen MN, Smoll NR, Hildebrandt G, Schaller K, Gautschi OP. Early surgical education of residents is safe for microscopic lumbar disc surgery. Acta Neurochir (Wien) 2014; 156:1205-14. [PMID: 24668216 DOI: 10.1007/s00701-014-2070-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 03/11/2014] [Indexed: 01/22/2023]
Abstract
INTRODUCTION It is a well-established dogma that many surgeons do not reach a quintessential level of their technical operative skills until successful completion of their training program. The aim of this study was to test the hypothesis that early introduction of supervised residents to non-complex spinal surgical procedures within a structured and supervised educational program does not harm the patient in terms of higher complication rates or worse pain- and health-related quality of life (HrQOL) outcomes. METHODS A prospective study on 102 patients undergoing surgery for lumbar disc herniation (LDH) was performed. The procedures were dichotomized into two groups according to the surgeon's level of experience: teaching cases (neurosurgical residents in the 1st to 4th year of training) and non-teaching cases (experienced board-certified faculty neurosurgeons). Pain levels (VAS) and the HrQOL using the 12-item short-form health survey (SF-12) were measured at baseline, at 4 weeks and as a survey at 1 year postoperatively. In addition, data concerning the operation and the postoperative course including common complications were assessed. RESULTS Intraoperative blood loss, length of surgery, as well as intra- and postoperative complications were similar between the study groups. Patients in both groups achieved equal results in terms of pain reduction after 4 weeks [mean VAS change -3.8 (teaching cases) vs. -3.1 (non-teaching cases), p = 0.25] and 1 year postoperatively [mean change in VAS -3.5 (teaching cases) vs. -3.37 (non-teaching cases), p = 0.84]. Teaching cases were 100 % (odds ratio of 1.00) as likely as non-teaching cases to achieve a favorable HrQOL response to surgery (p = 0.99). CONCLUSIONS Early introduction of resident surgeons to lumbar microdiscectomy can be conducted safely within a structured and supervised educational program as it neither harms the patient nor leads to worse 1-year results. Surgical resident education may thus be implemented safely in times of rigorous working laws. However, a structured education program in which the senior surgeon gives advice, guidance and communicates cautions during each resident surgery is of paramount importance to provide high-quality patient care.
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Affiliation(s)
- Martin N Stienen
- Department of Neurosurgery, Kantonsspital St.Gallen, Rorschacher Str. 95, 9007, St.Gallen, Switzerland,
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Comparison of outcomes after posterior spinal fusion for adolescent idiopathic and neuromuscular scoliosis: does the surgical first assistant's level of training matter? Spine (Phila Pa 1976) 2014; 39:648-55. [PMID: 24480953 DOI: 10.1097/brs.0000000000000233] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This was a retrospective review of posterior spinal fusion surgical procedures in patients diagnosed with adolescent idiopathic scoliosis (AIS) or neuromuscular scoliosis (NMS). OBJECTIVE The purpose was to determine if the first assistant's training experience is associated with outcomes in AIS and NMS surgical procedures. SUMMARY OF BACKGROUND DATA A previous study found that patients with AIS undergoing posterior spinal fusion with 2 attendings had similar operating times, blood loss, and complication rates compared with those with a resident or fellow first assistant. NMS cases are more complex than AIS cases, but to our knowledge, no previous studies have examined the impact of the first assistant's level of training on NMS outcomes. METHODS This was a single-center retrospective review of 200 patients, 120 with AIS and 80 with NMS, undergoing primary posterior spinal fusion. Minimum follow-up was 2 years. For each diagnosis group, cases assisted by junior orthopedic residents were compared with those assisted by orthopedic fellows. RESULTS NMS cases were more complex and had higher complication rates than AIS cases (P < 0.05). AIS and NMS cases were similarly distributed among the fellow and junior resident groups (P = 0.63). AIS cases in the fellow and junior resident groups had similar operating times, estimated blood loss (EBL), complications, lengths of stay, and reoperation rates (P > 0.05). In NMS cases, the fellow group had shorter operating times (320 ± 73 min vs. 367 ± 104 min, P = 0.035) and greater percent correction at initial and 2-year follow-up (58 ± 15% vs. 42 ± 19%, P < 0.001). EBL, complications, lengths of stay, and reoperation rates were similar between the assistant groups in NMS cases (P > 0.05). CONCLUSION NMS surgical procedures in which fellows serve as the first assistants were associated with shorter operating times and greater percent correction than surgical procedures with junior resident first assistants. LEVEL OF EVIDENCE 3.
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Hoashi JS, Samdani AF, Betz RR, Bastrom TP, Cahill PJ. Is there a "July effect" in surgery for adolescent idiopathic scoliosis? J Bone Joint Surg Am 2014; 96:e55. [PMID: 24695932 DOI: 10.2106/jbjs.m.00150] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Prior studies in various medical and surgical specialties have suggested that the changeover of medical trainees in the United States at the end of the academic year, or so-called "July effect," negatively impacts the quality of patient care, including increasing morbidity and decreasing efficiency. We analyzed whether the outcomes of surgery for adolescent idiopathic scoliosis involving physicians-in-training as first assistants were affected by the time of year the surgery was performed. METHODS We performed a multicenter retrospective study with use of a prospectively collected database to examine outcomes following instrumented posterior spinal fusion in patients with adolescent idiopathic scoliosis. The minimum duration of follow-up was two years. The outcomes of procedures performed by twelve surgeons whose first assistants were all surgeons-in-training were analyzed on the basis of the month of year that the surgery was performed. Variables assessed included blood loss, operative time, length of hospitalization, radiographic outcomes, Scoliosis Research Society (SRS-22) scores, and complications. RESULTS Five hundred and seventy-five surgical procedures for adolescent idiopathic scoliosis were performed, most in June (14%) and July (13%) (p ≤ 0.001). Preoperative radiographic characteristics were similar across all months as were postoperative radiographic outcomes. Preoperative and two-year SRS-22 scores were also similar across all months, with the exception of scores in the preoperative pain domain, which showed worse pain for patients who underwent surgery in February. No significant differences in blood loss, operative time, or length of hospital stay were observed when these variables were analyzed on the basis of the month in which the surgery was performed. The rate of patients experiencing any complication (23.5% overall) was not associated with the month of surgery, nor were the rates for the specific subcategories of neurologic, pulmonary, gastrointestinal, instrumentation, or surgical site-related complications. With the exception of three gastrointestinal complications that were observed in July, the odds of a patient having a complication from surgery in July/August were unchanged from other months. CONCLUSIONS Overall, the data did not provide evidence to support a July effect. Our results suggest that surgery for adolescent idiopathic scoliosis during July and August yields safety and outcomes equal to that of other months.
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Affiliation(s)
- Jane S Hoashi
- Shriners Hospitals for Children, 3551 North Broad Street, Philadelphia, PA 19104
| | - Amer F Samdani
- Shriners Hospitals for Children, 3551 North Broad Street, Philadelphia, PA 19104
| | - Randal R Betz
- Shriners Hospitals for Children, 3551 North Broad Street, Philadelphia, PA 19104
| | - Tracey P Bastrom
- Rady Children's Hospital, 3030 Children's Way, Suite 410, San Diego, CA 92123
| | | | - Patrick J Cahill
- Shriners Hospitals for Children, 3551 North Broad Street, Philadelphia, PA 19104
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Schoenfeld AJ, Serrano JA, Waterman BR, Bader JO, Belmont PJ. The impact of resident involvement on post-operative morbidity and mortality following orthopaedic procedures: a study of 43,343 cases. Arch Orthop Trauma Surg 2013; 133:1483-91. [PMID: 23995548 DOI: 10.1007/s00402-013-1841-3] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Indexed: 02/09/2023]
Abstract
BACKGROUND Few studies have addressed the role of residents' participation in morbidity and mortality after orthopaedic surgery. The present study utilized the 2005-2010 National Surgical Quality Improvement Program (NSQIP) dataset to assess the risk of 30-day post-operative complications and mortality associated with resident participation in orthopaedic procedures. METHODS The NSQIP dataset was queried using codes for 12 common orthopaedic procedures. Patients identified as having received one of the procedures had their records abstracted to obtain demographic data, medical history, operative time, and resident involvement in their surgical care. Thirty-day post-operative outcomes, including complications and mortality, were assessed for all patients. A step-wise multivariate logistic regression model was constructed to evaluate the impact of resident participation on mortality- and complication-risk while controlling for other factors in the model. Primary analyses were performed comparing cases where the attending surgeon operated alone to all other case designations, while a subsequent sensitivity analysis limited inclusion to cases where resident participation was reported by post-graduate year. RESULTS In the NSQIP dataset, 43,343 patients had received one of the 12 orthopaedic procedures queried. Thirty-five percent of cases were performed with resident participation. The mortality rate, overall, was 2.5 and 10 % sustained one or more complications. Multivariate analysis demonstrated a significant association between resident participation and the risk of one or more complications [OR 1.3 (95 % CI 1.1, 1.4); p < 0.001] as well as major systemic complications [OR 1.6 (95 % CI 1.3, 2.0); p < 0.001] for primary joint arthroplasty procedures only. These findings persisted even after sensitivity testing. CONCLUSIONS A mild to moderate risk for complications was noted following resident involvement in joint arthroplasty procedures. No significant risk of post-operative morbidity or mortality was appreciated for the other orthopaedic procedures studied. LEVEL OF EVIDENCE II (Prognostic).
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Affiliation(s)
- Andrew J Schoenfeld
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, Texas Tech University Health Sciences Center, 5005 N. Piedras Street, El Paso, TX, 79920, USA,
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Abstract
STUDY DESIGN Retrospective review of prospectively collected surgical data. OBJECTIVE This study sought to determine the effect of fellow education during the course of the academic year (August-July) on surgical outcomes in adolescent idiopathic scoliosis. One surgeon and one type of surgery were chosen to minimize confounding factors. SUMMARY OF BACKGROUND DATA Educating and training the next generation of physicians and surgeons is necessary for the survival and continuation of medical care. There has been recent momentum to document scientifically that medical education is safe. Spine surgery is complex and demanding, with a steep learning curve, making it an ideal model to detect any potential negative impact of medical education. SUBJECTS adolescent patients undergoing posterior spinal surgery, between August 2007 and July 2010, by a single senior surgeon at one institution with a fellow as the only surgical assistant. Demographic and perioperative data were collected and then segmented by surgical date into quarters according to the rotations of the academic year. One fellow was included in each quarter during the 4 years, resulting in 16 fellows across the 4 quarters. An analysis of variance model was used to assess differences in operative time, blood loss, length of stay, and complications between the quarters of the year. RESULTS There were no significant differences between the groups regarding age, sex, or Lenke curve type. No statistically significant differences were found between the 4 quarters of the fellowship year for estimated blood loss, use of cell saver, length of stay, operative time, and complication rate. CONCLUSION This study is the first to show that fellow education during the course of the academic year did not impact the patient outcomes studied. It is clear that while there is significant academic benefit for the fellows as they complete their spine fellowship, there is no negative impact for patients. LEVEL OF EVIDENCE 4.
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Halanski MA, Elfman CM, Cassidy JA, Hassan NE, Sund SA, Noonan KJ. Comparing results of posterior spine fusion in patients with AIS: Are two surgeons better than one? J Orthop 2013; 10:54-8. [PMID: 24403750 DOI: 10.1016/j.jor.2013.03.001] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Accepted: 03/30/2013] [Indexed: 11/30/2022] Open
Abstract
AIMS Spinal deformity surgery is one of the most complicated procedures performed in pediatric orthopedics. These surgeries can account for long operative times and blood losses. Finding ways to limit patient morbidity undergoing these procedures may benefit many. We hypothesized that utilizing two fellowship trained pediatric spinal deformity surgeons would lead to decreased operative time and blood loss when compared with single surgeon. We felt very little difference would be found in terms of curve correction. METHODS A retrospective review of spinal deformity surgeries performed at two institutions was performed. At one institution, the standard of care was to have two fellowship deformity trained surgeons perform all deformity surgeries simultaneously, while at the second institution posterior spinal fusions performed by individual surgeons were performed. The single surgeon cohort was further divided based on instrumentation type (pedicle screw vs hybrid constructs). Cases for this review were limited to posterior spinal fusions without osteotomies in patients with idiopathic or idiopathic like curves. Cohorts were compared pre-operatively for age at surgery, sex, BMI, largest Cobb angle. Intra-operative comparisons included total EBL, instrumentation type screws vs hybrid, levels fused, and operative time. Comparisons between largest remaining Cobb, EBL/level, time/level, lowest recorded Hb, allogenic transfusion requirements, length of PICU stay, and total length of hospital stay were then made. Pair-wise student t-tests was performed between cohorts with significance defined as a p-value of 0.05 or less. CONCLUSIONS Twenty-four patients were found in the (BMP) cohort, where as eighty-two were found in the control group. No significant difference in age, sex, starting hemoglobin, BMI*, or maximum pre-operative Cobb between cohorts was found. A significantly lower number of levels were fused in the BMP cohort than the control (9 ± 2 vs 11 ± 2) p < 0.001, and likewise a significantly shorter operative time (average >2 h) was seen in the BMP cohort. Interestingly, no difference in estimated blood loss, blood loss/level fused, operative time/level fused was observed, yet a significantly greater drop in hemoglobin (average 1 g) p = 0.001 and allogenic transfusion rate was seen in the control group (4% (1/24) vs 29% (24/82)) p = 0.01. A greater improvement in Cobb angle was seen in the BMP group 46 ± 8 vs 35 ± 10° p < 0.001. No differences were seen in nights in the PICU and peri-operative complications, however patients in the BMP averaged nearly 1day less in the hospital than in the control group. Utilizing a blood management program including two surgeons in spinal deformity surgery appears to decrease operative time, blood loss, and improve curve correction. Confounding factors such as differences in number of fusion levels, curve types, instrumentation type, and institutional practices prevents drawing definitive conclusions. This is the first study to show potential benefits of utilizing a blood management program with dual surgeons in spinal deformity cases.
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Affiliation(s)
- Matthew A Halanski
- University of Wisconsin, UWMF Centennial Building, Madison, WI 53705, USA
| | - Corey M Elfman
- University of Wisconsin, UWMF Centennial Building, Madison, WI 53705, USA
| | | | - Nabil E Hassan
- Helen DeVos Children's Hospital, Grand Rapids, MI 49503, USA
| | - Sarah A Sund
- University of Wisconsin, UWMF Centennial Building, Madison, WI 53705, USA
| | - Kenneth J Noonan
- University of Wisconsin, UWMF Centennial Building, Madison, WI 53705, USA
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van der Leeuw RM, Lombarts KMJMH, Arah OA, Heineman MJ. A systematic review of the effects of residency training on patient outcomes. BMC Med 2012; 10:65. [PMID: 22742521 PMCID: PMC3391170 DOI: 10.1186/1741-7015-10-65] [Citation(s) in RCA: 103] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 06/28/2012] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Residents are vital to the clinical workforce of today and tomorrow. Although in training to become specialists, they also provide much of the daily patient care. Residency training aims to prepare residents to provide a high quality of care. It is essential to assess the patient outcome aspects of residency training, to evaluate the effect or impact of global investments made in training programs. Therefore, we conducted a systematic review to evaluate the effects of relevant aspects of residency training on patient outcomes. METHODS The literature was searched from December 2004 to February 2011 using MEDLINE, Cochrane, Embase and the Education Resources Information Center databases with terms related to residency training and (post) graduate medical education and patient outcomes, including mortality, morbidity, complications, length of stay and patient satisfaction. Included studies evaluated the impact of residency training on patient outcomes. RESULTS Ninety-seven articles were included from 182 full-text articles of the initial 2,001 hits. All studies were of average or good quality and the majority had an observational study design. Ninety-six studies provided insight into the effect of 'the level of experience of residents' on patient outcomes during residency training. Within these studies, the start of the academic year was not without risk (five out of 19 studies), but individual progression of residents (seven studies) as well as progression through residency training (nine out of 10 studies) had a positive effect on patient outcomes. Compared with faculty, residents' care resulted mostly in similar patient outcomes when dedicated supervision and additional operation time were arranged for (34 out of 43 studies). After new, modified or improved training programs, patient outcomes remained unchanged or improved (16 out of 17 studies). Only one study focused on physicians' prior training site when assessing the quality of patient care. In this study, training programs were ranked by complication rates of their graduates, thus linking patient outcomes back to where physicians were trained. CONCLUSIONS The majority of studies included in this systematic review drew attention to the fact that patient care appears safe and of equal quality when delivered by residents. A minority of results pointed to some negative patient outcomes from the involvement of residents. Adequate supervision, room for extra operation time, and evaluation of and attention to the individual competence of residents throughout residency training could positively serve patient outcomes. Limited evidence is available on the effect of residency training on later practice. Both qualitative and quantitative research designs are needed to clarify which aspects of residency training best prepare doctors to deliver high quality care.
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Affiliation(s)
- Renée M van der Leeuw
- Professional Performance Research Group, Department of Quality Management and Process Innovation, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
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