Adam M Ali

The use of robotics in surgery: a review.

There is an ever‐increasing drive to improve surgical patient outcomes. Given the benefits which robotics has bestowed upon a wide range of industries, from vehicle manufacturing to space exploration, robots have been highlighted by many as essential for continued improvements in surgery.

Factors Associated With 30-Day Readmission After Primary Total Hip Arthroplasty: Analysis of 514 455 Procedures in the UK National Health Service

Importance Thirty-day readmission to hospital after total hip arthroplasty (THA) has significant direct costs and is used as a marker of hospital performance. All-cause readmission is the only metric in current use, and risk factors for surgical readmission and those resulting in return to theater (RTT) are poorly understood. Objective To determine whether patient-related predictors of all-cause, surgical, and RTT readmission after THA differ and which predictors are most significant. Design, Setting, and Participants Analysis of all primary THAs recorded in the National Health Service (NHS) Hospital Episode Statistics database from 2006 to 2015. The effect of patient-related factors on 30-day readmission risk was evaluated by multilevel logistic regression analysis. The analysis comprised all acute NHS hospitals in England and all patients receiving primary THA. Main Outcomes and Measures Thirty-day readmission rate for all-cause, surgical (defined using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision primary admission diagnoses), and readmissions resulting in RTT. Results Across all hospitals, 514 455 procedures were recorded. Seventy-nine percent of patients were older than 60 years, 40.3% were men, and 59.7% were women. There were 30 489 all-cause readmissions (5.9%), 16 499 surgical readmissions (3.2%), and 4286 RTT readmissions (0.8%); 54.1% of readmissions were for surgical causes. Comorbidities with the highest odds ratios (ORs) of RTT included those likely to affect patient behavior: drug abuse (OR, 2.22; 95% CI, 1.34-3.67; P = .002), psychoses (OR, 1.83; 95% CI, 1.16-2.87; P = .009), dementia (OR, 1.57; 95% CI, 1.11-2.22; P = .01), and depression (OR, 1.52; 95% CI, 1.31-1.76; P < .001). Obesity had a strong independent association with RTT (OR, 1.46; 95% CI, 4.45-6.43; P < .001), with one of the highest population attributable fractions of the comorbidities (3.4%). Return to theater in the index episode was associated with a significantly increased risk of RTT readmission (OR, 5.35; 95% CI, 4.45-6.43; P < .001). Emergency readmission to the hospital in the preceding 12 months increased the risk of readmission significantly, with the association being most pronounced for all-cause readmission (for >2 emergency readmissions, OR, 2.33; 95% CI, 2.11-2.57; P < .001). Hip resurfacing was associated with a lower risk of RTT when compared with cemented implants (OR, 0.69; 95% CI, 0.54-0.88; P = .002) but for other types of readmission, implant type had no significant association with readmission risk. Increasing age and length of stay were strongly associated with all-cause readmission. Conclusions and Relevance Many patient-related risk factors for surgical and RTT readmission differ from those for all-cause readmission despite the latter being the only measure in widespread use. Clinicians and policy makers should consider these alternative readmission metrics in strategies for risk reduction and cost savings.

The Role of Stress in Optimizing Surgical Performance

In their evaluation of a method that assesses surgical workload, Wilson et al. [1] made the assumption that intraoperative stress is necessarily detrimental to surgical performance. However, the Yerkes–Dodson law [2] dictates that increasing levels of stress improve performance up to a point, beyond which further stress causes performance to diminish. Thus, if our objective is to improve outcomes, the important metric is not surgeons’ subjective evaluation of their stress level but an objective evaluation of how different intraoperative conditions impact upon performance, especially given that the stress–performance relationship will differ between surgeons. References

What is the objective of personal healthcare budgets

It is crucial to define the function of personal healthcare budgets in the evolving NHS.1 The debate so far has assumed that patients will use their budget to choose from an existing set of services to meet their needs, but that the system will not be used as a lever …

Comparison of 3 Types of Readmission Rates for Measuring Hospital and Surgeon Performance After Primary Total Hip and Knee Arthroplasty

BACKGROUND All-cause 30-day hospital readmission is in widespread use for monitoring and incentivizing hospital performance for patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, little is known on the extent to which all-cause readmission is influenced by hospital or surgeon performance and whether alternative measures may be more valid. METHODS This is an observational study using multilevel modeling on English administrative data to determine the interhospital and intersurgeon variation for 3 readmission metrics: all-cause, surgical, and return-to-theater. Power calculations estimated the likelihood of identifying whether the readmission rate for a surgeon or hospital differed from the national average by a factor of 1.25, 1.5, 2, or 3 times, for both average and high-volume providers. RESULTS 259,980 THAs and 311,033 TKAs were analyzed. Variations by both surgeons and hospitals were smaller for the all-cause measure than for the surgical or return-to-theater metrics, although statistical power to detect differences was higher. Statistical power to detect surgeon-level rates of 1.25 or 1.5 times the average was consistently low. However, at the hospital level, the surgical readmission measure showed more variation by hospital while maintaining excellent power to detect differences in rates between hospitals performing the average number of THA or TKA cases per year in England. In practice, more outliers than expected from purely random variation were found for all-cause and surgical readmissions, especially at hospital level. CONCLUSION The 30-day surgical readmission rate should be considered as an adjunctive measure to 30-day all-cause readmission rate when assessing hospital performance.

Use of a Composite Metric to Assess Hospital Performance after Hip Fracture

meta-analysis due to exclusion of groups most at risk”. J Am Geriatr Soc 2017;65:661. 3. Vochteloo AJ, Moerman S, van der Burg BL et al. Delirium risk screening and haloperidol prophylaxis program in hip fracture patients is a helpful tool in identifying high-risk patients, but does not reduce the incidence of delirium. BMC Geriatr 2011;11:39,2318-11-39. 4. Moher D, Liberati A, Tetzlaff J et al. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Ann Intern Med 2009;339:b2535. 5. Hakim SM, Othman AI, Naoum DO. Early treatment with risperidone for subsyndromal delirium after on-pump cardiac surgery in the elderly: A randomized trial. Anesthesiology 2012;116:987–997. 6. Kalisvaart KJ, de Jonghe J, Bogaards MJ et al. Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: A randomized placebo-controlled study. J Am Geriatr Soc 2005;53:1658–1666. 7. Prakanrattana U, Prapaitrakool S. Efficacy of risperidone for prevention of postoperative delirium in cardiac surgery. Anaesth Intensive Care 2007;35:714–719. 8. American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults. American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults. J Am Geriatr Soc 2015;63:142–150. 9. American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults. Postoperative delirium in older adults: Best practice statement from the American Geriatrics Society. J Am Coll Surg 2015;220:136–148.

Choice and equality in health

The US aversion to a single payer system highlights a fundamental difference in mentality between the United States and the United Kingdom that the US government would do well to remember.1 To many Americans the term single payer represents socialised medicine and government bureaucracy, while in the NHS …

Kinematic alignment of current TKA implants does not restore the native trochlear anatomy

INTRODUCTION Preserving constitutional patellofemoral anatomy, and thus producing physiological patellofemoral kinematics, could prevent patellofemoral complications and improve clinical outcomes after kinematically aligned TKA (KA TKA). Our study aims 1) to compare the native and prosthetic trochleae (planned or implanted), and 2) to estimate the safety of implanting a larger Persona® femoral component size matching the proximal lateral trochlea facet height (flange area) in order to reduce the native articular surfaces understuffing generated by the prosthetic KA trochlea. METHODS Persona® femoral component 3D model was virtually kinematically aligned on 3D bone-cartilage models of healthy knees by using a conventional KA technique (group 1, 36models, planned KA TKA) or an alternative KA technique (AT KA TKA) aiming to match the proximal (flange area) lateral facet height (10 models, planned AT KA TKA). Also, 13postoperative bone-implant (KA Persona®) models were co-registered to the same coordinate geometry as their preoperative bone-cartilage models (group 2implanted KA TKA). In-house analysis software was used to compare native and prosthetic trochlea articular surfaces and medio-lateral implant overhangs for every group. RESULTS The planned and performed prosthetic trochleae were similar and valgus oriented (6.1 and 8.5, respectively), substantially proximally understuffed compared to the native trochlea. The AT KA TKAs shows a high rate of native trochlea surface overstuffing (70%, 90%, and 100% for lateral facet, groove, medial facet) and mediolateral implant overhang (60%). There was no overstuffing with conventional KA TKAs having their anterior femoral cut flush. CONCLUSION We found that with both the planned and implanted femoral components, the KA Persona® trochlea was more valgus oriented and understuffed compared to the native trochlear anatomy. In addition, restoring the lateral trochlea facet height by increasing the femoral component size generated a high rate of trochlea overstuffing and mediolateral implant overhang. While restoring a native trochlea with KA TKA is not possible, the clinical impact of this is low, especially on PF complications. In current practice it is better to undersize the implants even if it does not restore the native anatomy. Longer follow-up is needed for KA TKAs performed with current implant, and the debate of developing new, more anatomic, implants specifically designed for KA technique is now opened. LEVEL OF EVIDENCE II, Laboratory controlled study.

Immobilisation in occipital condyle fractures: A systematic review

OBJECTIVES The objectives of this review are to determine the level of evidence for the management of OCF, compare outcomes of different immobilisation, and to review the prognosis. PATIENTS AND METHODS A literature search was conducted using 3 databases (MEDLINE, PubMed and EMBASE). All papers between 1940 and July 2017 were screened using PRISMA guidelines. Inclusion criteria were patients with a confirmed diagnosis of occipital condyle fracture(s) on CT managed with any form of immobilisation with no age restriction. Primary outcome was clinical improvement in symptoms or Neck Disability Index. MINORS and OCEBM level was assigned to each study. RESULTS 25 studies met the inclusion criteria. Most studies used a single form of C-spine immobilisation support (58%) with a semi rigid collar and halo device being the most common. From these studies, the average length of time for immobilisation was 11.7 weeks, 9 weeks and 8.3 weeks for halo, semi-rigid and rigid cervical collars respectively. Neuro deficit was found in 20.3% of patients. OCEBM level of evidence and MINORS score was low. CONCLUSION Management of OCF is associated with low level of evidence. Further studies are needed to determine optimal management of these under-diagnosed fractures.

Vertebral compression fractures

This review gives a practical guide to the investigation and management of osteoporotic vertebral compression fractures. With an ageing population, the burden of disease and health system costs attributable to this common injury continue to rise. This article outlines the epidemiology, clinical and radiological assessment of vertebral compression fractures, and key decisions that must be made in their management. It reviews the indications and evidence for conservative vs operative treatment, discusses the rationale for vertebroplasty, kyphoplasty and spinal stabilization, and looks at outcomes in this vulnerable patient population. It also reviews key evidence underlying decision making including National Institute for Health and Care Excellence guidelines.