CORR Synthesis: How Have Film Review and Motion Analysis Been Used to Enhance Orthopaedic Surgical Performance?

Same-Day Versus Staged Spinal Fusion: A Meta-analysis of Clinical Outcomes

STUDY DESIGN

Meta-analysis.

OBJECTIVE

This meta-analysis aims to compare same-day versus staged spine surgery, assessing their effects on patient care and health care system efficiency.

BACKGROUND

In spinal surgery, the debate between whether same-day and staged surgeries are better for patients continues, as the decision may impact patient-related outcomes, health care resources, and overall costs. While some surgeons advocate for staged surgeries, citing reduced risks of complications, others proclaim same-day surgeries may minimize costs and length of hospital stays.

METHODS

PubMed, Cochrane, and Google Scholar (pages 1-20) were searched up until February 2024. The studied outcomes were operative room (OR) time, estimated blood loss (EBL), length of hospital stay (LOS), overall complications, venous thromboembolism (VTE), death, operations, and nonhome discharge.

RESULTS

Sixteen retrospective studies were included in this meta-analysis, representing a total of 2346 patients, of which 644 underwent staged spinal fusion surgeries and 1702 same-day surgeries. No statistically significant difference was observed in EBL between staged and same-day surgery groups. However, the staged group exhibited a statistically significant longer OR time ( P =0.05) and LOS ( P =0.004). A higher rate of overall complications ( P =0.002) and VTE ( P =0.0008) was significantly associated with the staged group. No significant differences were found in the rates of death, reoperations, and nonhome discharge between the 2 groups.

CONCLUSIONS

Both staged and same-day spinal fusion surgeries showed comparable rates of death, operations, and nonhome discharges for patients undergoing spinal surgeries. However, given the increased OR time, LOS, and complications associated with staged spinal surgeries, this study supports same-day surgeries when possible to minimize the burden on healthcare resources and enhance efficiency.

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.

The Case for Operative Efficiency in Adult Spinal Deformity Surgery: Impact of Operative Time on Complications, Length of Stay, Alignment, Fusion Rates, and Patient-Reported Outcomes

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVE

To analyze the impact of operative room (OR) time in adult spinal deformity (ASD) surgery on patient outcomes.

BACKGROUND

It is currently unknown if OR time in ASD patients matched for deformity severity and surgical invasiveness is associated with patient outcomes.

MATERIALS AND METHODS

ASD patients with baseline and two-year postoperative radiographic and patient-reported outcome measures (PROM) data, undergoing a posterior-only approach for long fusion (>L1-Ilium) were included. Patients were grouped into short OR time (<40th percentile: <359 min) and long OR time (>60th percentile: >421 min). Groups were matched by age, baseline deformity severity, and surgical invasiveness. Demographics, radiographic, PROM data, fusion rate, and complications were compared between groups at baseline and two years follow-up.

RESULTS

In total, 270 patients were included for analysis: the mean OR time was 286 minutes in the short OR group versus 510 minutes in the long OR group ( P <0.001). Age, gender, percent of revision cases, surgical invasiveness, pelvic incidence minus lumbar lordosis, sagittal vertical axis, and pelvic tilt were comparable between groups ( P >0.05). Short OR had a slightly lower body mass index than the short OR group ( P <0.001) and decompression was more prevalent in the long OR time ( P =0.042). Patients in the long group had greater hospital length of stay ( P =0.02); blood loss ( P <0.001); proportion requiring intensive care unit ( P =0.003); higher minor complication rate ( P =0.001); with no significant differences for major complications or revision procedures ( P >0.5). Both groups had comparable radiographic fusion rates ( P =0.152) and achieved improvement in sagittal alignment measures, Oswestry disability index, and Short Form-36 ( P <0.001).

CONCLUSION

Shorter OR time for ASD correction is associated with a lower minor complication rate, a lower estimated blood loss, fewer intensive care unit admissions, and a shorter hospital length of stay without sacrificing alignment correction or PROMs. Maximizing operative efficiency by minimizing OR time in ASD surgery has the potential to benefit patients, surgeons, and hospital systems.