Allogeneic versus autogenous shell technique augmentation procedures: a prospective-observational clinical trial comparing surgical time and complication rates

OBJECTIVES

Autogenous and allogeneic blocks for shell augmentation of the jaw have shown comparable results. This observational clinical study aimed to compare both materials for shell augmentation concerning surgery time and intra- and postoperative complications.

MATERIAL AND METHODS

Bone augmentation with the shell technique using autogenous or allogenous bone was performed in 117 patients with segmental jaw atrophy. The primary study parameter was the surgical time, comparing both materials. Subsequently, intra- and postoperative complications were recorded.

RESULTS

Allogeneic (n = 60), autogenous (n = 52), or both materials (n = 5) were used. The use of allogeneic material led to a significantly shorter operation time (p < 0.001). A more experienced surgeon needed significantly less time than a less experienced surgeon (p < 0.001). An increasing number of bone shells (p < 0.001), an additional sinus floor elevation, and intraoperative complications also significantly increased the operation time (p = 0.001). Combining allogeneic and autogenous shells (p = 0.02) and simultaneous sinus floor elevation (p = 0.043) significantly impacted intraoperative complications. No correlations were found between the included variables for postoperative complications (all p > 0.05). In total, 229 implants were inserted after a healing time of 4-6 months, with a survival of 99.6% after a mean follow-up duration of 9 months.

CONCLUSIONS

Compared to the autogenous technique, allogeneic shell augmentation has a shorter surgical time and a similar rate of intra- and postoperative complications as autogenous bone. Together with its promising clinical results, this technique can be recommended.

The learning curve to ROSA: cases needed to match the surgery time between a robotic-assisted and a manual primary total knee arthroplasty

PURPOSE

Limited published data regarding the ROSA (Robotic Surgical Assistant) learning curve exist. This study evaluated the number of cases needed for an expert orthopaedic surgeon to master the ROSA system and match the operative time of robotic (raTKAs) and manual primary total knee arthroplasties (mTKAs).

METHODS

This retrospective comparative cohort study included two hundred patients with primary knee osteoarthritis. The study group consisted of an expert surgeon's first 100 raTKAs. The control group included 100 patients that underwent mTKAs from the same surgeon during the same period. The consecutive cases in each group were divided into ten subgroups, each of 10 cases. The groups were comparable concerning age, sex, BMI and Kellgren-Lawrence classification. We compared each subgroup's operative time and complications in mTKA and raTKA groups. We performed a cumsum analysis to construct the ROSA learning curve.

RESULTS

The first non-significant difference between the mTKAs and raTKAs operative times was observed in the subgroup of 62 to 71 cases. Till then, the operative time has been significantly lower for the mTKA than the raTKA group. The following groups of tens analysis (8th, 9th and 10th) showed no operative time difference between groups. The learning curve analysis demonstrated that the surgeon switched to the mastering phase from case 73 onwards. The two groups had no complication rate differences.

CONCLUSION

Our study demonstrated that about 70 cases are necessary for a senior surgeon to balance operative time between mTKAs and raTKAs using the ROSA system.

Real-time estimation of the remaining surgery duration for cataract surgery using deep convolutional neural networks and long short-term memory

PURPOSE

Estimating the surgery length has the potential to be utilized as skill assessment, surgical training, or efficient surgical facility utilization especially if it is done in real-time as a remaining surgery duration (RSD). Surgical length reflects a certain level of efficiency and mastery of the surgeon in a well-standardized surgery such as cataract surgery. In this paper, we design and develop a real-time RSD estimation method for cataract surgery that does not require manual labeling and is transferable with minimum fine-tuning.

METHODS

A regression method consisting of convolutional neural networks (CNNs) and long short-term memory (LSTM) is designed for RSD estimation. The model is firstly trained and evaluated for the single main surgeon with a large number of surgeries. Then, the fine-tuning strategy is used to transfer the model to the data of the other two surgeons. Mean Absolute Error (MAE in seconds) was used to evaluate the performance of the RSD estimation. The proposed method is compared with the naïve method which is based on the statistic of the historical data. A transferability experiment is also set to demonstrate the generalizability of the method.

RESULT

The mean surgical time for the sample videos was 318.7 s (s) (standard deviation 83.4 s) for the main surgeon for the initial training. In our experiments, the lowest MAE of 19.4 s (equal to about 6.4% of the mean surgical time) is achieved by our best-trained model for the independent test data of the main target surgeon. It reduces the MAE by 35.5 s (-10.2%) compared to the naïve method. The fine-tuning strategy transfers the model trained for the main target to the data of other surgeons with only a small number of training data (20% of the pre-training). The MAEs for the other two surgeons are 28.3 s and 30.6 s with the fine-tuning model, which decreased by -8.1 s and -7.5 s than the Per-surgeon model (average declining of -7.8 s and 1.3% of video duration). External validation study with Cataract-101 outperformed 3 reported methods of TimeLSTM, RSDNet, and CataNet.

CONCLUSION

An approach to build a pre-trained model for estimating RSD estimation based on a single surgeon and then transfer to other surgeons demonstrated both low prediction error and good transferability with minimum fine-tuning videos.

Delayed surgery is associated with adverse outcomes in patients with hip fracture undergoing hip arthroplasty

BACKGROUND

Hip arthroplasty (HA) is one of the most effective procedures for patients with hip fractures. The timing of surgery played a significant role in the short-term outcome for these patients, but conflicting evidence has been found.

METHODS

The Nationwide Inpatient Sample database was investigated from 2002 to 2014 and identified 247,377 patients with hip fractures undergoing HA. The sample was stratified into ultra-early (0 day), early (1-2 days) and delayed (3-14 days) groups based on time to surgery. Yearly trends, postoperative surgical and medical complications, postoperative length of hospital stay (POS) and total costs were compared after propensity scores were matched between groups by demographics and comorbidity.

RESULTS

From 2002 to 2014, the percentage of hip fracture patients who underwent HA increased from 30.61 to 31.98%. Early surgery groups showed fewer medical complications but higher surgical complications. However, specific complication evaluation showed both ultra-early and early groups decreased most of the surgery and medical complications with increasing post hemorrhagic anemia and fever. Medical complications were also reduced in the ultra-early group, but surgical complications increased. Early surgery groups reduced the POS by 0.90 to 1.05 days and total hospital charges by 32.6 to 44.9 percent than delayed surgery groups. Ultra-early surgery showed no benefit from POS than early group, but reduced total hospital charges by 12.2 percent.

CONCLUSION

HA surgery performed within 2 days showed more beneficial effects on adverse events than delayed surgery. But surgeons should be cognizant of the potential increased risks of mechanical complications and post-hemorrhagic anemia.

Audiological outcome after stapes surgery in relation to prosthesis type

PURPOSE

Different techniques are used to fix crimp and CliP® Piston stapes prostheses to the long process of the incus (LPI). The CliP® Piston provides a stiff connection in contrast to the static bended loop of the crimp prosthesis, which imitates the physiological incudostapedial joint (ISJ) and thereby potentially leads to different hearing outcome.

METHODS

In a retrospective single-center study of German-speaking one hundred and ninety patients who underwent stapes surgery CliP® Piston or crimp prostheses between the years of 2016 and 2019 by the same surgeon and in the same setting. Pre- and postoperative bone- (BC) and air-conduction (AC) pure-tone thresholds, pre- and postoperative air-bone gap (ABG) for 0.5, 1, 1.5, 2, 3, 4 kHz and the surgery time were examined.

RESULTS

The postoperative bone conduction thresholds were significantly lower in the frequencies between 0.5 and 3 kHz and the mean ABG was < 10 dB in most cases independent of the prosthesis used. Crimp prosthesis showed a significantly better closure of the ABG at 0.5 kHz.

CONCLUSIONS

The audiological outcome after stapes surgery is dependent on the type of prosthesis used, as reflected by the frequency-specific air-bone gap. The better ABG closure with the crimp prosthesis might be the result of the connection to the LPI imitating the physiological ISJ. The crimp prosthesis may be the better choice if use of hearing aids is expected postoperatively.

Setting a quality indicator for actual surgery time relative to scheduled surgery time in the context of increasing robotic-assisted thoracic surgery cases

OBJECTIVE

This study aimed to demonstrate to the involved departments the goal of increasing the number of robotic-assisted thoracic surgery (RATS) cases/surgeons and acceptable surgery times.

METHODS

This retrospective study included 1572 patients who underwent thoracic surgery from fiscal year (FY) 2018 to FY 2021. The factors evaluated included the number of surgery cases and actual and scheduled surgery times.

RESULTS

The total number of RATS and total surgery cases increased after the quality indicator (QI) setting (n = 363, 360, 417, and 432 in FY 2018, 2019, 2020, and 2021, respectively). In FY 2020, 93.3% of the QI target was achieved, while in FY 2021, 88% was achieved. The number of RATS lobectomy/segmentectomy increased as the FY progressed (n = 31, 47, 58, and 116 in FY 2018, 2019, 2020, and 2021, respectively). The mean surgical time by RATS starters decreased in FY 2020 and 2021 (171.4 min.; 74 cases; seven RATS starters) compared with those in FY 2018 and 2019 (198.0 min.; 57 cases; six RATS starters) (P = 0.002).

CONCLUSIONS

The goal of increasing the number of surgery cases and RATS cases/surgeons within the given framework was achieved by setting the QI.

Risk factors for surgical site infection associated with clean surgical procedures in dogs

Surgical site infection (SSI) is associated with increased morbidity, cost and mortality in human medicine and with increased morbidity and cost in veterinary medicine. The aim of this study was to evaluate risk factors for SSI development after clean surgical procedures in dogs, treated at both first opinion clinics as well as referral hospitals. 1550 dogs scored 1 or 2 according to the American Society of Anesthesiologists (ASA), that underwent clean surgical procedures at 103 clinics located in Northern and Central Europe were included in the study. Data regarding the surgical procedure, surgery time use of perioperative antimicrobial prophylaxis (AMP), surgery type, intraoperative hypothermia, and the use of surgical implants were recorded according to predefined protocols. Active 30-day SSI surveillance was performed. A random effects logistic regression model was used to evaluate the association between the perioperative variables and SSI development. SSI was detected in 85/1550 dogs (5.5%); 25 occurred in the 500 orthopedic/neurosurgery procedures (5.0%), and 60 in the 1050 soft tissue procedures (5.7%). A total of 1524 dogs were included in the final multivariable model. Increased surgery time was the only variable associated with an increased risk of SSI. No association between the other risk factors evaluated in the study and SSI occurrence was detected. Efforts must therefore be made to keep the surgery time as short as possible. Orthopedic and neurosurgical procedures including those where an implant is placed should not automatically be regarded as high-risk procedures benefiting from perioperative AMP.

Comparison of 27-gauge versus 25-gauge vitrectomy results in patients with epiretinal membrane: 6-month follow-up

PURPOSE

To compare the 27G versus 25G vitrectomy in patients with epiretinal membrane (ERM).

PATIENTS AND METHODS

Sixty pseudophakic eyes of 60 consecutive patients treated by pars plana vitrectomy (PPV) using 27G (30 eyes) or 25G (30 eyes) were prospectively evaluated including eye's inflammation, surgery time, ERM + ILM removal time and complications. Additionally, 1, 3, 7, 14, 30, 90 and 180 days after PPV, the following were estimated: intraocular pressure (IOP), sclerotomy wound closure time, distance best corrected visual acuity (DBCVA), foveal macular thickness (FMT) and surgically induced astigmatism (SIA).

RESULTS

The eye's inflammation resolved within 30 days after surgery in both groups. The surgery and ERM + ILM times were longer in the 27G group (p ≤ 0.02). The most common postoperative complication was hypotony in both groups, more common in 25G group (23.3% vs. 10% of eyes). In 27G group, the mean IOP prior to 180 days postoperatively was higher (p < 0.05) and the sclerotomy wound closure time was shorter (p < 0.001). Mean DBCVA values (7, 14, 30 days after surgery) were significantly better in 27G group (p < 0.001). The mean FMT values were similarly and significantly reduced in both groups 1 day postoperatively (p < 0.05) as compared to preoperative values and then stabilized during follow-up. Mean SIA was lower in 27G group 30, 90 and 180 days after surgery (p < 0.001).

CONCLUSION

The use of 27G PPV in patients with ERM significantly reduced sclerotomy wound closure time and surgically induced astigmatism, better stabilized intraocular pressure and allowed to achieve faster visual acuity improvement, as compared to 25G PPV.

Does the surgery time affect the final outcome of type III supracondylar humeral fractures?

INTRODUCTION

Supracondylar humeral fractures are common in the pediatric population, with displaced fractures requiring operative intervention. The purpose of this study was to look at our practice and assess whether a difference in clinical outcomes and requirement for open reduction was observed if surgery was delayed.

METHODS

This was a retrospective medical record and plain radiograph review of patients admitted with type III Gartland supracondylar fractures between January 2014 and December 2015. The patients were seen for up to 12 months postoperatively, and clinical assessment was performed at this stage.

RESULTS

There were 116 supracondylar humeral fractures admitted between January 2014 and December 2015, 23 of which were Gartland type III. The mean age of the patients was 6 years, and the mean time from emergency department presentation to surgery was 14 h. Seven of the 23 patients required conversion to open reduction. There were no reported complications and all fractures demonstrated radiographic union. The length of time to surgery did not increase the number of cases requiring open reduction. The results demonstrated that there was no difference in clinical outcomes found between those that had closed manipulation or required conversion to open reduction, nor the time taken to surgery.

CONCLUSION

This study suggest that patients who present with type III supracondylar humeral fractures and have no neurovascular deficit, a delay in pinning of 12 h or more may not result in a significant difference in the need for open reduction or clinical outcomes.

LEVEL OF EVIDENCE

Level IV.

Accuracy of the Precision Saw versus the Sagittal Saw during total knee arthroplasty: A randomised clinical trial

BACKGROUND

The aim of this study was to compare the accuracy of the oscillating tip saw system (Precision Saw=PS) with the more conventional fully oscillating blade system (Sagittal Saw=SS) during computer-assisted total knee arthroplasty (CAS-TKA).

METHODS

A prospective, randomised, controlled trial included 58 consecutive patients who underwent primary CAS-TKA and were randomly assigned in the PS group or the SS group to compare the accuracy of both blades. The primary outcome was the difference between the intended cutting planes and the actual cutting planes in degrees (°) in two planes of both the femur and the tibia. The secondary outcome was total surgery time.

RESULTS

Tibia: In the VV-plane no significant differences were registered for the mean absolute deviation (p=0.28). The PS was more accurate in the AP-plane (p=0.03). Femur: The PS showed significantly fewer mean absolute deviations in the VV-plane (p=0.03); however, the SS revealed better accuracy in the FE-plane (p=0.04). The difference in the surgery time between the groups was not statistically significant (p=0.45). Two outliers were measured using the SS, while seven outliers were detected using the PS.

CONCLUSION

The Precision Saw is not proven to be overall more accurate than the Sagittal Saw. Significantly better accuracy was shown with the PS in the two cutting planes, with the exception of one cutting plane that favoured the SS. Greater number of outliers were found using the PS.

LEVEL OF EVIDENCE

II.

The effect of surgery time on prognosis in newborns with meningomyelocele

OBJECTIVE

To investigate the effect of surgery time on prognosis of newborns with meningomyelocele.

METHODS

The records of neonates with meningomyelocele were retrospectively analyzed. Demographic and clinical characteristics as well as information, timing of surgery, and durations of hospital stay and antibiotic therapy were recorded.

RESULTS

The records of 30 babies were included in the final analysis. Overall, the mean gestational age was 37.7±2.7 weeks, with a mean birth weight of 2967±755 g and head circumference of 35.8±3.8 cm. In terms of localization, 46.6% of the meningomyeloceles were lumbosacral, 40% were lumbar, 10% were thoracolumbar and 3.3% were thoracal. The mean size of the meningomyelocele sacs was 4.33±1.2 cm. Newborns underwent surgery on average of 8.2±5.9 days after birth, with an overall mean duration of hospital stay of 30±25.1 days. Patients were divided into two groups based on timing of surgery (group 1, ≤5 days; group 2, >5 days), and comparisons between groups revealed that earlier surgery was associated with significantly shorter durations of hospital stay (p<0.001) and antibiotic therapy (p<0.05).

CONCLUSION

Early surgical intervention (≤5 days) was associated with a shorter duration of hospital stay and antibiotic therapy as well as a lower complication rate. We recommend that corrective surgery be undertaken as soon as reasonably possible.