Surgical Ergonomics and Musculoskeletal Pain in Arthroplasty Surgeons

Surgeons Experience Greater Physiologic Stress and Strain in the Direct Anterior Approach Than the Posterior Approach for Total Hip Arthroplasty

BACKGROUND

The direct anterior approach (DAA) and posterior approach (PA) for total hip arthroplasty (THA) have advantages and disadvantages, but their physiologic burden to the surgeon has not been quantified. This study was conducted to determine whether differences exist in surgeon physiological stress and strain during DAA in comparison to PA.

METHODS

We evaluated a prospective cohort of 144 consecutive cases (67 DAA and 77 PA). There were 5, high-volume, fellowship-trained arthroplasty surgeons who wore a smart-vest that recorded cardiorespiratory data while performing primary THA DAA or PA. Heart rate (beats/minute), stress index (correlates with sympathetic activations), respiratory rate (respirations/minute), minute ventilation (L/min), and energy expenditure (calories) were recorded, along with patient body mass index and operative time. Continuous data was compared using t-tests or Mann Whitney U tests, and categorical data was compared with Chi-square or Fischer's exact tests.

RESULTS

There were no differences in patient characteristics. Compared to PA, performing THA via DAA had a significantly higher surgeon stress index (17.4 versus 12.4; P < .001), heart rate (101 versus 98.3; P = .007), minute ventilation (21.7 versus 18.7; P < .001), and energy expenditure per hour (349 versus 295; P < .001). However, DAA had a significantly shorter operative time (71.4 versus 82.1; P = .001).

CONCLUSIONS

Surgeons experience significantly higher physiological stress and strain when performing DAA compared to PA for primary THA. This study provides objective data on energy expenditure that can be factored into choice of approach, case order, and scheduling preferences, and provides insight into the work done by the surgeon.

Therapeutic Interventions for Prevention of Musculoskeletal Pain Among Orthopedic Surgeons

Orthopedic surgery is a physically demanding specialty. The factors contributing to musculoskeletal injury among surgeons often stem from positioning the patient, using non-ergonomic instruments, maintaining static postures, and performing repetitive movements. This article focuses on exercise techniques intended to combat the most common problematic static postures held during procedures. Each exercise explained in this article is organized into "preop," "intraop," and "postop" components. Preop includes strengthening movements, intraop provides postural recommendations, and postop focuses on mobilization and recovery. This article aims for efficient body conditioning, targeting the muscular posterior chain and supporting elements. [Orthopedics. 2024;47(4):e214-e216.].

Increased arthroplasty surgeon energy consumption when performing primary total hip arthroplasty compared to total knee arthroplasty

Introduction

Previously published studies have hypothesized that total hip arthroplasty (THA) requires the surgeon to expend more energy that total knee arthroplasty (TKA). However, techniques for performing these procedures have evolved. Therefore, we sought to compare if primary THA had increased energy expenditure compared to primary TKA.

Methods

We prospectively recorded the heart rate, respiratory rate, minute ventilation, cadence, and energy expenditure of a single fellowship-trained arthroplasty surgeon while performing primary THA and TKA on 372 patients. Patient demographics and operative records were reviewed to evaluate differences in the physical demands of each surgical case. Age (64.3 versus 65.9 years, p = 0.1) and gender (54.8% versus 51.0% female, p = 0.5) were similar between THA and TKA, but TKAs had a higher body mass index (31.1 versus 28.7 kg/m2, p < 0.001). Chi-square and independent-samples t-tests were used to compare cohorts. Significance was set at p < 0.05.

Results

THA tended to have 1.1 times longer operative time than TKA (102.2 versus 88.9 min, p < 0.001). THA had a statistically higher heart rate compared to TKA, although this is unlikely to be clinically significant (82.5 versus 80.7 beats/minute, p < 0.001). Respiratory Rate was 1.1 times higher (15.9 versus 14.9 respirations/minute, p < 0.001) and minute ventilation was 1.2 times higher (19.6 versus 16.9 L/min, p < 0.001) when performing THA. Cadence was 1.5 times higher when performing TKA (4.2 versus 2.8 steps/minute, p < 0.001). THA had a 1.2 times higher energy expenditure/patient (378.8 versus 312.0 Calories/patient, p < 0.001) and a 1.1 times higher energy expenditure/minute (3.7 versus 3.5 Calories/minute, p = 0.01) compared to TKA.

Discussion

THA is associated with longer operative time and increased energy expenditure per compared to TKA. Despite THA and TKA procedures becoming more efficient, arthroplasty surgery continues to have heavy physical burden on the surgeon. Further research is needed to understand ways to decrease surgeon energy expenditure and promote career longevity.

The influence of virtual reality simulation on surgical residents' heart rate during an assessment of arthroscopic technical skills: A prospective, paired observational study

HYPOTHESIS

To demonstrate that a virtual reality (VR) simulation training program reduces heart rate variability during an assessment of surgical trainees' technical skills in arthroscopy.

STUDY DESIGN

Prospective observational matched study.

MATERIALS & METHODS

Thirty-six orthopaedic surgery residents, new to arthroscopy, received standard training in arthroscopic knee surgery, supplemented by additional monthly training for 6months on a VR simulator for 16 of them. At inclusion, the 2 groups (VR and NON-VR) answered a questionnaire and performed a meniscectomy on a VR simulator. After 6months of training, two independent trainers blinded to the inclusion arms evaluated the technical skills of the two groups during meniscectomies on a model and on an anatomical subject. Heart rate variability (HRV) was measured using a wireless heart rate monitor during baseline, VR training, and assessment.

RESULTS

After removing incomplete data, the analysis focused on 10 VR residents matched at inclusion with 10 NON-VR residents. The VR group had a significantly lower heart rate at the final assessment (p=0.02) and lower overall HRV (p=0.05). The low/high frequency ratio (LF/HF) was not significantly different between the groups (1.84 vs 2.05, p=0.66) but the before-after training comparison showed a greater decrease in this ratio in the VR group compared to the NON-VR group -0.76 (-41%) vs -0.08 (-4%).

CONCLUSION

This study demonstrates a significant difference in heart rate variability between trained residents versus untrained residents during the final assessment of their technical skills at 6months. It appears that improving stress management should be an integral part of training programs in arthroscopic surgery.

CLINICAL INTEREST

VR simulators in arthroscopy could improve non-technical skills such as heart rate variability, from the perspective of accountability.

LEVEL OF EVIDENCE

III.

Overcoming Barriers: Sex Disparity in Surgeon Ergonomics

BACKGROUND

Musculoskeletal discomfort is widely experienced by surgeons across multiple surgical specialties. Developing technologies and new minimally invasive techniques add further complexity and ergonomic stressors. These stressors differentially affect male and female surgeons, but little is known about the role these sex disparities play in surgical ergonomic stress. We reviewed existing literature to better understand how ergonomic stress varies between male and female surgeons.

STUDY DESIGN

A literature search was performed via PubMed including but not limited to the following topics: ergonomics, surgeons, female surgeons, women surgeons, pregnancy, and operating room. A review of available quantitative data was performed.

RESULTS

Female surgeons endure more pronounced ergonomic discomfort than their male counterparts, with added ergonomic stress associated with pregnancy.

CONCLUSIONS

A 4-fold method is proposed to overcome ergonomic barriers, including (1) improved education on prevention and treatment of ergonomic injury for active surgeons and trainees, (2) increased departmental and institutional support for ergonomic solutions for surgeons, (3) partnerships with industry to study innovative ergonomic solutions, and (4) additional research on the nature of surgical ergonomic challenges and the differential effects of surgical ergonomics on female surgeons.

Increased patient body mass index is associated with increased surgeon physiologic stress during total hip arthroplasty

INTRODUCTION

While increased body mass index (BMI) in patients undergoing total hip arthroplasty (THA) increases surgical complexity, there is a paucity of objective studies assessing the impact of patient BMI on the cardiovascular stress experienced by surgeons during THA. The aim of this study was to assess the impact of patient BMI on surgeon cardiovascular strain during THA.

METHODS

We prospectively evaluated three fellowship-trained arthroplasty surgeons performing a total of 115 THAs. A smart-vest worn by the surgeons recorded mean heart rate, stress index (correlate of sympathetic activation), respiratory rate, minute ventilation, and energy expenditure throughout the procedures. Patient demographics as well as perioperative data including surgical approach, surgery duration, number of assistants, and the timing of the surgery during the day were collected. Linear regression was utilized to assess the impact of patient characteristics and perioperative data on cardiorespiratory metrics.

RESULTS

Average surgeon heart rate, energy expenditure, and stress index during surgery were 98.50 beats/min, 309.49 cal/h, and 14.10, respectively. Higher patient BMI was significantly associated with increased hourly energy expenditure (P = 0.027), mean heart rate (P = 0.037), and stress index (P = 0.027) independent of surgical approach. Respiratory rate and minute ventilation were not associated with patient BMI. The number of assistants and time of surgery during the day did not impact cardiorespiratory strain on the surgeon.

CONCLUSION

The physiologic burden on surgeons during primary THA significantly increases as patient BMI increases. This study suggests that healthcare systems should consider adjusting reimbursement models to account for increased surgeon workload due to obesity. Further surgeons should adopt strategies in operative planning and case scheduling to handle this added physical strain.

LEVEL OF EVIDENCE

III.

High Prevalence of Work-related Musculoskeletal Disorders and Limited Evidence-based Ergonomics in Orthopaedic Surgery: A Systematic Review

BACKGROUND

The Centers for Disease Control defines work-related musculoskeletal disorders as disorders of the nerves, muscles, tendons, joints, spinal discs, and cartilage that are caused or exacerbated by the environment or nature of work. Previous meta-analyses have characterized work-related musculoskeletal disorders among interventionists, general surgeons, and other surgical subspecialties, but prevalence estimates, prognosis, and ergonomic considerations vary by study and surgical specialty.

QUESTIONS/PURPOSES

(1) What is the career prevalence of work-related musculoskeletal disorders in orthopaedic surgeons? (2) What is the treatment prevalence associated with work-related musculoskeletal disorders in orthopaedic surgeons? (3) What is the disability burden of work-related musculoskeletal disorders in orthopaedic surgeons? (4) What is the scope of orthopaedic surgical ergonomic assessments and interventions?

METHODS

A systematic review of English-language studies from PubMed, MEDLINE, Embase, and Scopus was performed in December 2022 and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies that presented prevalence estimates of work-related musculoskeletal disorders or assessed surgical ergonomics in orthopaedic surgery were included. Reviews, case reports, gray literature (conference abstracts and preprints), and studies with mixed-surgeon (nonorthopaedic) populations were excluded. The search yielded 5603 abstracts; 24 survey-based studies with 4876 orthopaedic surgeons (mean age 48 years; 79% of surgeons were men) were included for an analysis of work-related musculoskeletal disorders, and 18 articles were included for a descriptive synthesis of ergonomic assessment. Quality assessment using the Joanna Briggs Institute Tool revealed that studies had a low to moderate risk of bias, largely because of self-reporting survey-based methodology. Because of considerable heterogeneity and risk of bias, prevalence outcomes were not pooled and instead are presented as ranges (mean I 2 = 91.3%).

RESULTS

The career prevalence of work-related musculoskeletal disorders in orthopaedic surgeons ranged from 37% to 97%. By anatomic location, the prevalence of work-related musculoskeletal disorders in the head and neck ranged from 4% to 74%; back ranged from 9% to 77%; forearm, wrist, and hand ranged from 12% to 54%; elbow ranged from 3% to 28%; shoulder ranged from 3% to 34%; hip and thigh ranged from 1% to 10%; knee and lower leg ranged from 1% to 31%; and foot and ankle ranged from 4% to 25%. Of orthopaedic surgeons reporting work-related musculoskeletal disorders, 9% to 33% had a leave of absence, practice restriction or modification, or early retirement, and 27% to 83% received some form of treatment. Orthopaedic surgeons experienced biomechanical, cardiovascular, neuromuscular, and metabolic stress during procedures. Interventions to improve orthopaedic surgical ergonomics have been limited, but have included robotic assistance, proper visualization aids, appropriate use of power tools, and safely minimizing lead apron use. In hip and knee arthroplasty, robotic assistance was the most effective in improving posture and reducing caloric expenditure. In spine surgery, proper use of surgical loupes was the most effective in improving posture.

CONCLUSION

Although the reported ranges of our main findings were wide, even on the low end of the reported ranges, work-related musculoskeletal disability among orthopaedic surgeons appears to be a substantial concern. We recommend that orthopaedic residency training programs incorporate surgical ergonomics or work injury lectures, workshops, and film review (alongside existing film review of surgical skills) into their curricula. We suggest hospitals engage in shared decision-making with surgeons through anonymous needs assessment surveys to implement wellness programs specific to surgeons' musculoskeletal needs. We urge institutions to assess surgeon ergonomics during routine quality assessment of novel surgical instruments and workflows.

LEVEL OF EVIDENCE

Level III, prognostic study.

Effect of an upper body exoskeleton for surgeons on postoperative neck, back, and shoulder complaints

OBJECTIVES

Surgeons are exposed to high levels of physical stress while working in the operating room. In industry, so-called exoskeletons are used to support the back and shoulder area. The aim of this study was to investigate the feasibility and effects of an upper body exoskeleton on postoperative physical complaints of surgeons.

METHODS

Surgeons from a university hospital in the fields of orthopedics, trauma, and visceral surgery performed 2 operations of the same type and planned length on 2 different days. The first operation was performed without an exoskeleton, the second with an exoskeleton. The participants completed questionnaires on shoulder pain (Shoulder Pain and Disability Index [SPADI]), neck pain (Visual Analogue Scale [VAS] and Neck Disability Index [NDI]), and back pain (VAS and Oswestry Disability Index [ODI]) before and after the procedure.

RESULTS

A total of 25 participants were included and performed 50 surgeries with a mean surgery duration of 144 minutes without and 138 minutes with the exoskeleton. Without the exoskeleton, the activity of the operation resulted in a significant increase of the VAS neck by 1.0 point (SD 1.2; P < .001), NDI by 4.8 (SD 8.6; P = .010), VAS back by 0.7 (SD 1.0; P = .002), and ODI by 2.7 (SD 4.1; P = .003). With the exoskeleton the participants reported significantly fewer complaints after the surgery (VAS neck: P = .001; NDI: P = .003; VAS back: P = .036; ODI: P = .036; SPADI: P = .016).

CONCLUSION

An upper body exoskeleton can significantly reduce the discomfort in the neck, shoulder, and back caused to surgeons by surgery.

Shoulder Pain and Disability Scores and the Factors Influencing Them among Orthopedic Surgeons Working in the Kingdom of Saudi Arabia: A Cross-Sectional Study

(1) Background: Musculoskeletal pain is common among orthopedic surgeons. Their common musculoskeletal issues include shoulder pain and disability. Many associated factors could lead to this pain and disability; by identifying these, we can prevent orthopedic surgeons' pain and improve their functional capacity. (2) Methods: This study aimed to gather quantitative data regarding the shoulder pain and disability experienced by orthopedic surgeons. It also aimed to explore the potential correlations between demographic characteristics and work-related factors and their pain and disability. This study interviewed 150 orthopedic surgeons working in the Kingdom of Saudi Arabia, asking questions on the Shoulder Pain and Disability Index (SPADI) scale and about their demographic characteristics. (3) Results: All interviewed orthopedic surgeons were male, married, and nonsmokers. Their SPADI pain subsection score was 25.24%, their SPADI disability subsection score was 21.25%, and their total SPADI score was 22.79%. Among the examined demographic characteristics, total SPADI scores have a significant positive correlation with body weight (Spearman's ρ = 0.432; p < 0.05) and body mass index (BMI; ρ = 0.349; p < 0.05). (4) Conclusions: Our findings indicate that all orthopedic surgeons generally suffer from moderate shoulder pain and disability. Body weight and body mass index are important factors that may influence shoulder pain and disability among orthopedic surgeons.

Energy expenditure of femoral broaching in direct anterior total hip replacements-Comparison between manual and automated techniques

INTRODUCTION

Little information is known regarding the energy expenditure of the surgeon during total hip arthroplasty (THA). We sought to compare the energy expenditure associated with femoral broaching using two techniques: manual and automated.

METHODS

We recorded energy expenditure, minute ventilation, heart rate, and total broaching time of a single surgeon while broaching the femoral canal during direct anterior THA using two different techniques: Manual broaching (n = 26) and automated broaching (n = 20).

RESULTS

Manual broaching required a longer time than automated broaching (6.1 ± 1.1 vs. 3.7 ± 0.9 min; p < 0.001) with an increase in energy expenditure (32.6 ± 7.0 vs. 16.0 ± 7.1 Calories; p < 0.001). Heart rate was higher with manual broaching (99.4 ± 9.8 vs. 90.1 ± 9.8 beats per min; p = 0.003), along with minute ventilation (36.5 ± 7.0 vs. 30.3 ± 5.8 L/min; p = 0.003). There were no intraoperative complications.

CONCLUSIONS

Automated femoral broaching during THA can decrease the energy expenditure of broaching by 50% and time of broaching by 40%, when compared to manual technique.

CLINICAL TRIAL REGISTRATION

This research was not a clinical trial.

A narrative review of the physiology and health effects of burnout associated with veterinarian-pertinent occupational stressors

Chronic workplace stress and burnout are serious problems in veterinary medicine. Although not classified as a medical condition, burnout can affect sleep patterns and contributes to chronic low grade systemic inflammation, autonomic imbalance, hormonal imbalances and immunodeficiencies, thereby increasing the risks of physical and psychological ill health in affected individuals. Cultural misconceptions in the profession often lead to perceptions of burnout as a personal failure, ideas that healthcare professionals are somehow at lower risk for suffering, and beliefs that affected individuals can or should somehow heal themselves. However, these concepts are antiquated, harmful and incorrect, preventing the design of appropriate solutions for this serious and growing challenge to the veterinary profession. Veterinarians must first correctly identify the nature of the problem and understand its causes and impacts before rational solutions can be implemented. In this first part of two companion reviews, burnout will be defined, pathophysiology discussed, and healthcare and veterinary-relevant occupational stressors that lead to burnout identified.

UKA with a handheld robotic device results in greater surgeon physiological stress than conventional instrumentation

PURPOSE

Poor ergonomics and acute stress can impair surgical performance and cause work-related injuries. Robotic assistance may optimize these psychophysiological factors during UKA. This study compared surgeon physiologic stress and ergonomics during robotic-assisted UKA (rUKA) and conventional UKA (cUKA).

METHODS

Cardiorespiratory and postural data from a single surgeon were recorded during 30 UKAs, (15 rUKAs, 15 cUKAs). Heart rate (HR), HR variability, respiratory rate (RR), minute ventilation and calorie expenditure were used to measure surgical strain. Intraoperative ergonomics were assessed by measuring flexion/extension/rotation of the neck and lumbar spine, and shoulder abduction/adduction.

RESULTS

Mean operative time was 32.0 ± 7 min for cUKA and 45.9 ± 9 min for rUKA (p < 0.001). Mean neck flexion was - 23.4° ± 13° for rUKA and - 49.1° ± 18 for cUKA (p < 0.001), while mean lumbar flexion was - 20.3° ± 30° for rUKA and - 0.4° ± 68° for cUKA (p = 0.313). Mean lumbar flexion was similar; however, a significantly greater percentage of time was spent in lumbar flexion > 20° during cUKA. Bilateral shoulder abduction was significantly higher for rUKA. Mean calorie expenditure was 154 cal for rUKA and 89.1 cal for cUKA (p < 0.001). Mean HR was also higher for rUKA (88.7 vs. 84.7, p = 0.019). HR variability was slightly lower for rUKA (12.4) than for cUKA (13.4), although this did not reach statistical significance (p = 0.056). No difference in RR or minute ventilation was observed.

CONCLUSION

rUKA resulted in less neck flexion but increased shoulder abduction, heart rate, and energy expenditure. The theoretical ergonomic and physiologic advantages of robotic assistance using a handheld sculpting device were not realized in this study.

LEVEL OF EVIDENCE

II.

The Biomechanical Burden of Orthopaedic Procedures and Musculoskeletal Injuries Sustained by Orthopaedic Surgeons: A Systematic Review

BACKGROUND

Orthopaedic surgeons are at high risk for experiencing work-related musculoskeletal (MSK) injuries and chronic pain due to repetitive large magnitude forces, altered posture from lead vests, and prolonged irregular body positions. We sought to synthesize available evidence regarding (1) the biomechanics of orthopaedic surgery and (2) MSK injuries sustained by orthopaedic surgeons with subsequent treatment and consequences.

METHODS

To conduct this systematic review, we queried 4 databases (PubMed, Embase, MEDLINE, and Web of Science) for original research studies presenting on the biomechanics of orthopaedic surgery or MSK injuries sustained by orthopaedic surgeons. Studies were excluded if they were not original research (i.e., reviews) or reported on non-MSK injuries and injuries in patients or nonorthopaedic specialists. The literature search yielded 3,202 publications, 34 of which were included in the final analysis.

RESULTS

Eight studies reported on the biomechanics of orthopaedic surgery. Surgeons spent an average 41.6% of operating time slouched. Head and whole spine angles were closest to natural standing position when using a microscope for visualization and with higher surgical field heights. Use of lead aprons resulted in a shifted weight distribution on the forefoot, gain in thoracic kyphosis, and increase in lateral deviation from postural loading. Twenty-six studies reported on MSK symptoms and injuries experienced by orthopaedic surgeons, with an overall prevalence from 44% to 97%. The most common body regions involved were lower back (15.2%-89.5%), hip/thigh (5.0%-86.6%), neck (2.4%-74%), hand/wrist (10.5%-54%), shoulder (7.1%-48.5%), elbow (3.1%-28.3%), knee/lower leg (7.9%-27.4%), and foot/ankle (7%-25.7%). Of surgeons with any reported MSK symptom or injury, 27% to 65.7% required nonoperative treatment, 3.2% to 34.3% surgery, and 4.5% to 31% time off work. Up to 59.3% of surgeons reported that their injuries would negatively influence their ability to perform surgical procedures in the future.

CONCLUSIONS

The orthopaedic surgeon population experiences a high prevalence of MSK symptoms and injuries, likely secondary to the biomechanical burdens of tasks required of them during strenuous operations.

LEVEL OF EVIDENCE

Level III. See Instructions for Authors for a complete description of levels of evidence.

Yoga as an Adjunct Therapy for Musculoskeletal Pain and Burnout in Orthopedic Surgery: A Trainee's Perspective

Orthopedic surgeons face significant physical and psychosocial stressors during their training as surgical residents and throughout their career. Aside from occupational hazards intrinsic to the profession, two notable and treatable concerns are musculoskeletal pain and emotional burnout, which have a reported prevalence as high as 97% and 56%, respectively, among orthopedic residents. Management of musculoskeletal pain and burnout is essential for promoting surgeon well being, education, and longevity as well as avoiding medical errors and compromises to patient care. This perspective manuscript describes the occupational challenges faced by orthopedic surgeons and promotes a habitual practice of yoga as an adjunct therapy for managing musculoskeletal pain and emotional burnout, and furthermore, introduces the need to reconsider gendered perceptions surrounding orthopedics and the practice of yoga in a profession largely comprised of men.

Occupational Hazards to the Joint Replacement Surgeon: How Can Technology Help Prevent Injury?

Occupational hazards pose varying threats to the joint replacement surgeon. Musculoskeletal pain due to the repetitive nature of performing joint arthroplasty is felt daily by most surgeons. The purpose of this paper is to offer a basic introduction and demonstrate the many ways technology utilized during total joint arthroplasty can help mitigate common occupational hazards for the arthroplasty surgeon. This paper guides readers through the evolution and drivers behind technology in joint arthroplasty, describes several technologies currently available, and discusses how certain aspects of this technology may work to improve surgeon and patient outcomes. We review how advanced technologies in arthroplasty may reduce physical and mental demand, improve reproducibility, and decrease complications. The decision to utilize advanced technology in joint arthroplasty is ultimately made on an individual level after careful consideration of available literature.

Stress and Strain During Total Joint Arthroplasty Are Not Impacted by Hand Dominance or Operative Laterality in Orthopedic Surgeons

BACKGROUND

Orthopedic surgeons experience significant musculoskeletal pain and work-related injuries while performing total joint arthroplasty (TJA). We sought to investigate the impact of operative extremity and surgeon limb dominance on surgeon physiologic stress and energy expenditure during TJA.

METHODS

This was a prospective cohort study conducted at a tertiary academic practice. Cardiorespiratory data was recorded continuously in 3 high-volume arthroplasty surgeons using a smart garment that measured heart rate (HR), HR variability, respiratory rate, minute ventilation, and energy expenditure (calories) during conventional total knee (TKA) and total hip arthroplasty (THA).

RESULTS

Surgeon 1 and 2 (right-handed) performed 21 right TKAs, 10 left TKAs, 13 right THAs, and 10 left THAs. Surgeon 3 (left-handed) performed 6 right TKAs, 9 left TKAs, 16 right THAs, and 10 left THAs. While performing TKA or THA, limb laterality had no significant impact on operative time and no significant differences existed in HR, HR variability, respiratory rate, minute ventilation, or energy expenditure for any right-handed or left-handed surgeons, regardless of the operative limb laterality. While performing TKA, consistently standing on the side of hand dominance was associated with decreased strain and stress, compared to always standing on the operative side.

CONCLUSION

This study suggests that surgeon hand dominance and operative limb laterality do not impact energy expenditure or physiologic strain during TJA. However, consistently standing on the side of hand dominance in TKA may lead to decreased physiologic strain and stress during surgery. Further study utilizing wearable technology during TJA may provide orthopedic surgeons with information about modifiable factors that contribute to differences in physiological parameters during surgery.

Total Knee Arthroplasty With Robotic Surgical Assistance Results in Less Physician Stress and Strain Than Conventional Methods

BACKGROUND

Poor surgical ergonomics and physiological stress have been shown to impair surgical performance and cause injuries. The prevalence of musculoskeletal pain among arthroplasty surgeons is inordinately high. This study compared surgeon stress and strain during robotic-assisted total knee arthroplasty (rTKA) and conventional TKA (cTKA).

METHODS

Continuous cardiorespiratory and ergonomic data of a single surgeon were measured during 40 consecutive unilateral TKAs (20 rTKAs, 20 cTKAs) using a smart garment and wearable sensors. Heart rate (HR), HR variability, respiratory rate, minute ventilation, and calorie expenditure were used as surrogate measures for physiological stress. Intraoperative ergonomics were assessed by measuring cervical and lumbar flexion, extension and rotation, and shoulder abduction/adduction.

RESULTS

Mean operative time was longer for rTKA (48.2 ± 9 vs 31.8 ± 7 min, P < .001). Calories expended per minute was lower for rTKA (2.53 vs 3.50, P < .001). Total calorie expenditure in rTKA cases 11-20 was significantly lower than the first 10 (107.1 ± 27 vs 137.6 ± 24, P = .015), and lower than cTKA (112.3 ± 37). Mean HR was lower for rTKA (81.5 ± 4 vs 90.1 ± 5, P < .001). Minute ventilation was also lower for rTKA (14.9 ± 1 vs 17.0 ± 1.0 L/min, P < .001). Mean lumbar flexion as well as the percentage of time spent in a demanding flexion position >20° were significantly lower during rTKA (P < .001).

CONCLUSION

rTKA resulted in less surgeon physiologic stress, energy expenditure per minute, and postural strain compared to cTKA. Robotic assistance may help to increase surgical efficiency and reduce physician workload, but further studies are needed to determine whether these benefits will reduce musculoskeletal pain and injury among surgeons.

Surgeons Experience Greater Cardiorespiratory Strain and Stress During Total Hip Arthroplasty Than Total Knee Arthroplasty

BACKGROUND

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are physically demanding, with a high prevalence of work-related injuries among arthroplasty surgeons. It is unknown whether there are differences in cardiorespiratory output for surgeons while performing THA and TKA. The objective of this study is to characterize whether differences in surgeon physiological response exist while performing primary THA vs TKA.

METHODS

This is a prospective cohort study including 3 high-volume, fellowship-trained arthroplasty surgeons who wore a smart garment that recorded cardiorespiratory data on operative days during which they were performing primary conventional TKA and THA. Variables collected included patient body mass index (BMI), operative time (minutes), heart rate, heart rate variability, respiratory rate, minute ventilation, and energy expenditure (calories).

RESULTS

Seventy-six consecutive cases (49 THAs and 27 TKAs) were studied. Patient BMI was similar between the 2 cohorts (P > .05), while operative time was significantly longer in TKAs (60.4 ± 12.0 vs 53.6 ± 11.8; P = .029). During THA, surgeons had a significantly higher heart rate (95.7 ± 9.1 vs 90.2 ± 8.9; P = .012), energy expenditure per minute (4.6 ± 1.23 vs 3.8 ± 1.2; P = .007), and minute ventilation (19.0 ± 3.0 vs 15.5 ± 3.3; P < .001) compared to TKA.

CONCLUSION

Surgeons experience significantly higher physiological strain and stress while performing THA. While scheduling THAs and TKAs, surgeons should consider the higher physical demand associated with THAs and ensure adequate personal preparation and sequence of cases.