Prolonged operative time increases risk of blood loss and transfusion requirements in revision hip surgery

Intraoperative navigation in surgical management of traumatic spine injury: a propensity score matching analysis

BACKGROUND

Traumatic spinal injury (TSI) can lead to severe morbidity and significant health care resource utilization. Intraoperative navigation (ION) systems have been shown to improve outcomes in some populations. However, controversy about the benefit of ION remains. To our knowledge, there is no large database analysis studying the outcomes of ION on TSI patients. Here we hope to compare complications and outcomes in patients with TSI undergoing spinal fusion of 3 or more levels with or without the use of ION.

METHODS

The 2015-2019 National Surgical Quality Improvement Program (NSQIP) database was queried for cases of posterior spinal instrumentation of 3 or more levels. This population was then selected for postoperative diagnosis consistent with TSI. The effect of prolonged operative time was analyzed for all patients. Propensity score matching analysis was performed to create ION case and non-ION control groups. Baseline demographic characteristics, complications, and outcome data were collected and compared between ION and non-ION groups.

RESULTS

A total of 1,034 patients were included in the propensity matched analysis. Among comorbidities, only obesity was significantly more likely in the non-ION group. There was no difference in case complexity between the two groups. ION was associated with higher incidence of prolonged operative time but was a negative independent predictor for sepsis. Prolonged operative time was a significant independent predictor for pulmonary embolism and requirement of transfusion in all patients. Discharge to home, readmission, and reoperation rates did not differ between TSI patients with or without ION.

CONCLUSIONS

Use of ION during posterior spinal fusion of 3 or more levels in TSI patients is not associated with worse outcomes. Prolonged operative time, rather than ION, appears to have a higher influence on the rate of complications in this population. Evaluation of ION in the context of specific populations and pathology is warranted to optimize its use.

Impact of Supine versus Prone Positioning on Segmental Lumbar Lordosis in Patients Undergoing ALIF Followed by PSF: A Comparative Study

Background: Anterior lumbar interbody fusion (ALIF) and posterior spinal fusion (PSF) play pivotal roles in restoring lumbar lordosis in spinal surgery. There is an ongoing debate between combined single-position surgery and traditional prone-position PSF for optimizing segmental lumbar lordosis. Methods: This retrospective study analyzed 59 patients who underwent ALIF in the supine position followed by PSF in the prone position at a single institution. Cobb angles were measured preoperatively, post-ALIF, and post-PSF using X-ray imaging. One-way repeated measures ANOVA and post-hoc analyses with Bonferroni adjustment were employed to compare mean Cobb angles at different time points. Cohen's d effect sizes were calculated to assess the magnitude of changes. Sample size calculations were performed to ensure statistical power. Results: The mean segmental Cobb angle significantly increased from preoperative (32.2 ± 13.8 degrees) to post-ALIF (42.2 ± 14.3 degrees, Cohen's d: -0.71, p < 0.0001) and post-PSF (43.6 ± 14.6 degrees, Cohen's d: -0.80, p < 0.0001). There was no significant difference between Cobb angles after ALIF and after PSF (Cohen's d: -0.10, p = 0.14). The findings remained consistent when Cobb angles were analyzed separately for single-screw and double-screw ALIF constructs. Conclusions: Both supine ALIF and prone PSF significantly increased segmental lumbar lordosis compared to preoperative measurements. The negligible difference between post-ALIF and post-PSF lordosis suggests that supine ALIF followed by prone PSF can be an effective approach, providing flexibility in surgical positioning without compromising lordosis improvement.

Dual plating in the metastatic distal humerus: Benefits may outweigh the risks

Background

Impending and complete pathologic fractures of the distal humerus are rare complications of metastatic cancer. Surgical treatment aims to quickly restore function and minimize pain. Plate and screw fixation (PSF) is a common method for addressing these lesions, but unlike in orthopaedic trauma, there are no clear guidelines for best management. While dual PSF theoretically provides better support and reduces the chance of reoperation due to tumor progression, single PSF is currently the more common choice.

Materials and methods

Between March 2008 and September 2021, 35 consecutive patients who underwent PSF for distal humerus metastasis or multiple myeloma were retrospectively reviewed. The proportion of patients who developed various postoperative complications, including infection, nonunion, deep vein thrombosis, tumor progression, and radial nerve palsy, as well as those requiring reoperation, was calculated. Mann-Whitney U test, Pearson's chi-squared, and Fisher's exact test were used to investigate differences between the single and dual PSF groups with statistical significance defined as p ≤ 0.05.

Results

There was no significant difference (p = 0.259) in revision rate, although 3 of 21 (14.3 %) single PSF patients required reoperation compared to 0 of 14 (0.0 %) dual PSF patients. The revisions were performed in one patient due to refracture and in two patients due to tumor progression. Although not statistically significant, a larger percentage of single PSF patients developed a postoperative complication compared to dual PSF patients [odds ratio 0.42 (95 % confidence interval 0.071 to 2.5); p = 0.431]. Single PSF did lead to shorter operative time compared to dual PSF [p < 0.001].

Conclusion

Dual PSF is non-inferior to single PSF and potentially results in fewer reoperations and postoperative complications in distal humerus pathologic lesions, although it leads to longer operative time. The current study is limited by small sample size due to the rarity of distal humerus metastatic lesions.

[Tips and tricks of cement removal in the case of revision surgery]

BACKGROUND

In Germany, current revision rates after arthroplasty range between 28-37%. In particular, remaining cement residues are causative for additional revision surgery after periprosthetic joint infection, which is why complete cement removal is of high importance. However, the removal of remaining cement residues often confronts the surgeon with technical challenges. Complication-free and complete cement removal requires extensive preoperative preparation in order to develop the best possible surgical strategy.

TREATMENT

Special instrument sets to facilitate cement removal in revision cases are available from various manufacturers. In addition to endoluminal approaches, access enhancements such as extended osteotomies exist to facilitate complete cement removal. Finally, the surgeon should be able to give the indication for an intraoperative procedural change after a defined time interval.

Risk Factors Analysis and Nomogram Model Establishment of Hidden Blood Loss in Overweight and Obese Elderly Patients After Total Hip Arthroplasty

Background

Total hip arthroplasty (THA) has become the first-choice treatment for elderly patients with end-stage hip disease. The high amount of hidden blood loss (HBL) in overweight and obese patients after THA not only affects rapid recovery, but also results in a greater economic burden. We aimed to identify risk factors that contribute to elevated HBL in overweight and obese patients after THA by retrospective analysis, and establish a nomogram prediction model for massive HBL in overweight and obese patients after THA.

Methods

A total of 505 overweight and obese patients treated with THA were included and randomly divided into modeling and validation sets according to a 7:3 ratio. The demographic and relevant clinical data of the patients were collected. The independent risk factors affecting HBL after THA in overweight and obese patients were obtained by Pearson, independent sample T-test, and multiple linear regression analyses. R software was used to establish a nomogram prediction model for postoperative HBL, as well as a receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA).

Results

HBL was 911±438 mL, accounting for 79.5±13.1% of the total perioperative blood loss (1104±468 mL). A multiple linear regression analysis showed that HBL was associated with necrosis of the femoral head, absence of hypertension, longer operative time, higher preoperative erythrocytes, and higher preoperative D-dimer levels. The areas under the ROC curve (AUC) for the modeling and validation sets were 0.751 and 0.736, respectively, while the slope of the calibration curve was close to 1. The DCA curve demonstrated a better net benefit at a risk of HBL ≥1000 ml in both the training and validation groups.

Conclusion

HBL was an important component of total blood loss (TBL) after THA in overweight and obese patients. Necrosis of the femoral head, absence of hypertension, longer operative time, higher preoperative erythrocytes, and higher preoperative D-dimer levels were independent risk factors for postoperative HBL in these patients. The predictive model constructed based these data had better discriminatory power and accuracy, and could result in better net benefit for patients.

The Watson Extraction System for removal of well-fixed femoral stems: A retrospective review of 10 cases

Background

Revision of well-fixed cementless femoral stems is a challenging and time-consuming aspect of revision hip arthroplasty. The Watson Extraction System (WES) is a novel, size-specific 3-D fabricated instrument that mimics the outer geometry of the implanted femoral stem. The device acts to cut circumferentially around the stem as it is impacted into place, effectively disrupting the bone-implant interface.

Methods

This is a retrospective review assessing the experience of 3 fellowship-trained adult reconstruction surgeons who used the WES to extract 10 well-fixed femoral stems during rTHA between 11/7/2020 and 11/7/2022. Outcomes and measures included: ability to remove the stem without a femoral osteotomy, femoral stem extraction time, incidence of femoral fracture, stem type used for reconstruction, blood loss, total surgical time, post-operative complications.

Results

No femoral osteotomies were required. The mean time for stem extraction was 7 min (range, 2-13), and there were 2 (20%) intra-operative femoral fractures. The stem type utilized for reconstruction included: 4 (40%) modular, tapered style stems, 3 (30%) antibiotic spacers, 2 (20%) primary style stems, and 1 (10%) ream and broach proximally porous stem. The mean blood loss was 425 ml (range, 200-800), total surgical time was 160 min (range, 107-232), and duration of follow-up was 7 months (range, 2-22 months).

Conclusion

The WES may mitigate the need for femoral osteotomy, reduce femoral stem extraction and overall intraoperative time, and decrease blood loss in rTHA. Further, reduced bone loss with use of this device may permit final reconstruction with a primary style stem.

Staged Repair of Simultaneous Bilateral Proximal Hamstring Rupture and 2 Year Outcome: A Case Report

CASE

A 53-year-old man presented with simultaneous, bilateral proximal hamstring ruptures. He underwent open, staged surgical repair of the proximal hamstrings, followed by a modified course of rehabilitation. At 2-year follow-up, the patient reports excellent outcomes.

CONCLUSION

Simultaneous, bilateral, 3-tendon rupture of the proximal hamstrings is a rare lower extremity injury. Surgical treatment of such injuries presents several unique challenges. Staged surgical repair is an effective treatment option.

Clinical outcomes and prediction nomogram model for postoperative hemoglobin < 80 g/L in patients following primary lumbar interbody fusion surgery

OBJECTIVE

To analyze the association between different postoperative hemoglobin (Hb) levels and postoperative outcomes in patients who have undergone primary lumbar interbody fusion, and to investigate the risk factors and establish a predictive nomogram mode for postoperative Hb < 80 g/L.

METHODS

We retrospectively analyzed 726 cases who underwent primary lumbar interbody fusion surgery between January 2018 and December 2021in our hospital. All patients were divided into three groups according to the postoperative Hb levels (< 70 g/L, 70-79 g/L, ≥ 80 g/L). The postoperative outcomes among the three groups were compared, and the risk factors for postoperative Hb < 80 g/L were identified by univariate and multivariable logistic regression analysis. Based on these independent predictors, a nomogram model was developed. Predictive discriminative and accuracy ability of the predicting model was assessed using the concordance index (C-index) and calibration plot. Clinical application was validated using decision curve analysis. Internal validation was performed using the bootstrapping validation.

RESULTS

Patients with postoperative Hb < 80 g/L had higher rates of postoperative blood transfusion, a greater length of stay, higher rates of wound complications, and higher hospitalization costs than those with postoperative Hb ≥ 80 g/L. Preoperative Hb, preoperative platelets, fusion segments, body mass index, operation time, and intraoperative blood loss independently were associated with postoperative Hb < 80 g/L. Intraoperative blood salvage was found to be a negative predictor for postoperative Hb < 80 g/L (OR, 0.21 [95% CI 0.09-0.50]). The area under the curve of the nomogram model was 0.950. After internal validations, the C-index of the model was 0.939. The DCA and calibration curve suggested that the nomogram model had a good consistency and clinical utility.

CONCLUSIONS

Postoperative Hb < 80 g/L in patients following primary lumbar interbody fusion surgery increased blood transfusions requirement and was independently associated with poor outcomes. A novel nomogram model was established and could conveniently predict the risk of postoperative Hb < 80 g/L in patients after this type of surgery.

Comparative study of Vancouver type B2 periprosthetic fractures treated by internal fixation versus stem revision

PURPOSE

Currently, accepted treatment for periprosthetic femoral fractures with loose femoral stem indicates its revision; however, recent studies have proposed treating Vancouver type B2 fractures via internal fixation without stem revision, particularly in the elderly or multi-morbid patients. Despite indications for stem revision, some surgeons tend to perform internal fixation. The main goal of this study was therefore to identify the parameters that were significantly different comparing internal fixation to stem revision for Vancouver type B2 fractures.

METHODS

Eighty-one Vancouver B2 periprosthetic femoral fractures, treated between 2010 and 2019, were analysed. The internal fixation (ORIF) and the revision groups were compared. Patients' age, BMI, American Society of Anaesthesiologists (ASA) score, anaesthesia type, operating time, blood loss, surgeons' experience, post-operative weight-bearing, length of hospital stay, and radiological outcome using AGORA roentgenographic assessment were analysed.

RESULTS

Patients chosen for ORIF were significantly older than those treated by stem revision (85.4 vs 75.1 years; p = 0.002). Blood loss was 390.7 and 1141.6 ml in the ORIF and revision groups, respectively (p < 0.0001). The surgical times were 134.5 and 225 min in the ORIF and revision groups, respectively (p < 0.0001). Our analysis of BMI, ASA score, anaesthesia type, length of hospital stay, surgeons' experience and radiological outcome, were not significantly different between the two groups.

CONCLUSION

Revision did not exhibit better radiological results; moreover, internal fixation resulted in significantly less perioperative blood loss and a shorter operating time, concluding that ORIF is a viable alternative to revision arthroplasty, particularly in older patients.

The Off-Table Technique Increases Operating Room Efficiency in Direct Anterior Hip Replacement

Background

When performing a total hip arthroplasty via the direct anterior approach (DAA), many orthopedic surgeons utilize an orthopedic traction table. This technique requires an expensive table, time for positioning, staff to operate the table, and time-consuming transitions when preparing the femur. Some surgeons advocate for an “off-table” technique to avoid these difficulties. In this paper, we compare operating room efficiency between on-table and off-table techniques.

Material and methods

We retrospectively reviewed patients undergoing total hip arthroplasty by a single surgeon across the transition from on-table to off-table DAA technique. Three cohorts were defined; the last 40 on-table hips, the first 40 off-table hips, followed by the second 40 hips. Timestamps from the operative record were recorded to calculate setup, surgical, takedown, and total room time. Implant fixation, patient demographic data, comorbidities, and complications were recorded.

Results

From cohort 1 to 2, there was a 7-minute (14.44%, P = .0002) improvement in setup time but no change in total room time. From cohort 2 to 3, there was an additional 7-minute (15.47%, P < .0001) improvement in setup time, 32-minute (25.88%, P < .0001) improvement in surgical time, and 40-minute (21.96%, P < .0001) improvement in total room time yielding cumulative changes from cohort 1 to 3 of 15 minutes (27.68%, P < .0001), 28 minutes (23.11%, P < .0001), and 43 minutes (23.37%, P < .0001), respectively. There was no correlation between height, weight, or body mass index and time at any interval.

Conclusion

Conversion to an off-table DAA technique offers an improvement in operating room efficiency. This is seen in setup, operative, and total room time. Implementation could allow for an additional case each day.

Simplifying the Combined Use of Fibula Flap and Anterolateral Thigh Flap for Oromandibular Reconstruction

Although the preferred technique for reconstruction of extensive composite oromandibular defects involves the use of a fibula flap for the inner mucosal lining and mandibular bone reconstruction and an anterolateral thigh flap for outer skin coverage and soft tissue replenishment, this approach is complicated and manpower-dependent. It also often involves prolonged operations requiring nighttime surgery with insufficient manpower in an era of restricted working hours for residents, which can negatively affect the surgical outcomes. Traditionally, the mucosal defect is first defined and the fibula flap is then dissected to ensure a size-matching skin flap for the inner lining. This flap is transferred first after mandibulectomy is completed, but is delayed by the fibula bone shaping process. Finalizing the flap inset is a sophisticated process involving the fibula bone, fibula skin, and anterolateral thigh skin. Thus, we developed a strategy to overcome the late start of fibula flap harvest, the delayed initiation of defect-site reconstruction, and the troublesome flap inset. Briefly, we dissected both flaps sequentially or simultaneously from contralateral limbs before the mucosal defect was defined, so that the flaps were ready in the daytime. Once the mandibulectomy was completed, we transferred the anterolateral thigh flap first while the fibula bone was shaped, and simplified the flap inset by using the anterolateral thigh skin for the inner lining and outer coverage and the fibula skin as a monitoring flap. We employed this approach in five patients and completed postmandibulectomy reconstruction in as fast as 4 hours.

Intraoperative and postoperative complications of gynecological laparoscopic interventions: incidence and risk factors

Purpose

The aims of this study were to determine the incidence of intraoperative and postoperative complications of laparoscopic gynecological interventions and to identify risk factors for such complications.

Methods

All patients who underwent laparoscopic interventions from September 2013 to September 2017 at the Department of Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital were identified retrospectively using a prospectively compiled clinical database. Binary logistic regression analysis was used to identify independent risk factors for intra- and postoperative complications.

Results

Data from 3351 patients were included in the final analysis. Overall, 188 (5.6%) intraoperative and 219 (6.5%) postoperative complications were detected. On multivariate analysis, age [odds ratio (OR), 1.03; 95% confidence interval (CI) 1.01–1.04], surgery duration (OR, 1.02; 95% CI 1.02–1.03), carbon dioxide use (OR, 0.99; 95% CI 0.99–1.00), and surgical indication (all p ≤ 0.01) were independent risk factors for intraoperative and duration of surgery (OR, 1.01; 95% CI 1.01–1.02; p ≤ 0.01), carbon dioxide use (OR, 0.99; 95% CI 0.99–1.00; p ≤ 0.01), hemoglobin drop (OR, 1.41; 95% CI 1.21–1.65; p ≤ 0.01), and ASA status (p = 0.04) for postoperative complications.

Conclusion

In this large retrospective analysis with a generally low incidence of complications (5.6% intraoperative and 6.5% postoperative complications), a representative risk collective was identified: Patients aged > 38 years, surgery duration > 99 min, benign or malignant adnex findings were at higher risk for intraoperative and patients with surgery duration > 94 min, hemoglobin drop > 2 g/dl and ASA status III at higher risk for postoperative complications.