Christopher M. Brusalis

Does Surgeon Experience Impact the Risk of Complications After Bernese Periacetabular Osteotomy

BackgroundBernese periacetabular osteotomy (PAO) is a technically challenging procedure with potential risk for major complications and a previously reported steep learning curve. However, the impact of contemporary hip preservation fellowships on the learning curve of PAO has not been established.Questions/purposes(1) What was the frequency of major complications during the PAO learning curve of two surgeons who recently graduated from hip preservation fellowships? (2) Is increasing level of experience associated with the risk of a complication and with operative time, a possible surrogate measure of surgical performance?MethodsWe retrospectively studied 81 PAOs performed by one of two surgeons who recently graduated from a hip preservation fellowship during their first 4 years of practice in two institutions. One of the surgeons participated as a fellow in 78 PAOs with an increasing level of responsibility during the course of 1 full year. The other surgeon performed 41 PAOs as a fellow during 6 months, also with an increasing level of responsibility during that time. There were 68 (84%) female and 13 (16%) male patients (mean age, 18 years; range, 10–36 years). The frequency of complications was recorded early and at 1 year after surgery and graded according to a validated classification system describing five grades of complications. Complications that required surgical intervention (Grade III) and life-threatening complications (Grade IV) were considered major complications. Persistent pain after surgery, although considered a failure of PAO, was not considered a surgical complication as a result of the multifactorial etiology of pain after hip-preserving surgery. However, early reoperation and revision surgery were counted as complications. To evaluate the association between increasing level of experience and the occurrence of complications, we divided each surgeon’s experience into his first 20 procedures (initial interval) and his second 20 (experienced interval) to test whether the incidence of complications or operative time was different between the two intervals. Because the association between experience and the likelihood of a complication was estimated to be consistent between the two surgeons, the analysis was performed with data pooled from the two surgeons. To test whether there was a difference in the likelihood of a complication in the initial and the experienced intervals, a multivariate logistic regression analysis was performed and the adjusted risk of a complication between the two intervals was calculated. Linear regression analyses were used to test the association between surgeon level of experience and operative time.ResultsThe overall incidence of major (Grade III or Grade IV) complications was 6% (95% confidence interval [CI], 2%–14%). These included deep infection (3% [three of 81]), intraoperative posterior column fracture (1% [one of 81]), and pulmonary embolism (1% [one of 81]). With the numbers available, the risk of a complication did not decrease with increasing surgeon experience. After controlling for body mass index and surgeon, the frequency of a complication did not decrease in the experienced interval relative to the initial interval (odds ratio, 0.78; 95% CI, 0.25–2.4; p = 0.6623). The adjusted risk difference between the experienced interval relative and the initial interval was 6% (95% CI, −11% to 23%). When experience was modeled as a continuous variable (number of PAOs performed), increasing experience was not associated with a lower likelihood of a complication (odds ratio per one PAO increase in experience, 0.99; 95% CI, 0.94–1.04; p = 0.5478). However, after adjusting for body mass index and surgeon, increased experience was associated with a reduction in operative time (slope [change in log operative time per one procedure increase in experience], −0.005; 95% CI, −0.009 to −0.0005; p = 0.0292). For every one additional PAO increase in experience, there was a 0.45% decrease in operative time (95% CI, 0.05%–0.86% decrease].ConclusionsWith a case exposure greater than 40 PAOs and progressive surgical responsibility during contemporary structured training, two young surgeons were able to perform PAO with a low risk of complications. However, even with that surgical experience before independent practice, surgical time decreased over the first 40 PAOs they performed independently. Our data may help guide orthopaedic residency and hip preservation fellowship programs in establishing training requirements and assessing competency in PAO.Level of EvidenceLevel III, therapeutic study.

Predictive Factors for Differentiating Between Septic Arthritis and Lyme Disease of the Knee in Children

BACKGROUND Differentiating between septic arthritis and Lyme disease of the knee in endemic areas can be challenging and has major implications for patient management. The purpose of this study was to identify a prediction rule to differentiate septic arthritis from Lyme disease in children presenting with knee pain and effusion. METHODS We retrospectively reviewed the records of patients younger than 18 years of age with knee effusions who underwent arthrocentesis at our institution from 2005 to 2013. Patients with either septic arthritis (positive joint fluid culture or synovial white blood-cell count of >60,000 white blood cells/mm(3) with negative Lyme titer) or Lyme disease (positive Lyme immunoglobulin G on Western blot analysis) were included. To avoid misclassification bias, undiagnosed knee effusions and joints with both a positive culture and positive Lyme titers were excluded. Historical, clinical, and laboratory data were compared between groups to identify variables for comparison. Binary logistic regression analysis was used to identify independent predictive variables. RESULTS One hundred and eighty-nine patients were studied: 23 with culture-positive septic arthritis, 26 with culture-negative septic arthritis, and 140 with Lyme disease. Multivariate binary logistic regression identified pain with short arc motion, history of fever reported by the patient or a family member, C-reactive protein of >4 mg/L, and age younger than 2 years as independent predictive factors for septic arthritis. A simpler model was developed that showed that the risk of septic arthritis with none of these factors was 2%, with 1 of these factors was 18%, with 2 of these factors was 45%, with 3 of these factors was 84%, or with all 4 of these factors was 100%. CONCLUSIONS Although septic arthritis of the knee and Lyme monoarthritis share common features that can make them difficult to distinguish clinically, the presence of pain with short arc motion, C-reactive protein of >4.0 mg/L, patient-reported history of fever, and age younger than 2 years were independent predictive factors of septic arthritis in pediatric patients. The more factors that are present, the higher the risk of having septic arthritis. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The 8-Strand Hamstring Autograft in Anterior Cruciate Ligament Reconstruction

Growing participation in youth athletics has resulted in increased numbers of anterior cruciate ligament (ACL) injuries in skeletally immature patients. Use of autogenous graft material has been associated with improved graft survival. However, pediatric patients sometimes possess hamstring tendons that produce smaller-diameter grafts than those prepared with adult autogenous materials. Smaller-diameter grafts may predispose younger patients to graft failure. We describe a technique that increases the diameter of the ACL construct through the use of an 8-strand autologous hamstring tendon graft. The 8-strand ACL autograft is commonly used in all-inside ACL reconstruction surgery.

Youth and Experience: The Effect of Surgeon Experience on Outcomes in Cerebral Palsy Scoliosis Surgery

BACKGROUND Series on the learning curve in spinal deformity surgery have been published, but none has addressed neuromuscular spinal deformity, comprised of arguably the most complex cases. We present the first multi-center analysis of the impact of surgeon experience on neuromuscular spinal deformity surgery. METHODS A multi-center prospective study of spinal deformity surgery for cerebral palsy (CP) with at least 2 years of follow-up provided the dataset for assessment. Surgeons were categorized into one of two groups based on their self-reported first year of practice: an experienced surgeons (ES) group included those with at least 10 years of experience at the time of surgery and a young surgeons (YS) group included those with fewer than 10 years of experience at time of surgery. Groups were compared in multiple pre-operative, operative, and post-operative outcomes. RESULTS The YS group had 8 surgeons who performed 59 surgeries; the ES group had 13 surgeons who performed 103 cases, with one surgeons cases distributed in both groups. The YS group had a greater proportion of patients with severe mental retardation (89.7% vs. 68.6%, p = .01). Duration of surgery was greater in the YS group (456 vs. 344 minutes, p < .001). The mean number of levels fused was greater in the ES group (15.9 vs. 15.6, p = .024), caused by increased variation in the upper level of fusion among the ES group. No significant differences were found between groups for estimated blood loss, length of hospitalization, or in percentage of Cobb correction. Years of experience of the operating surgeon was inversely correlated with duration of surgery (rho = -0.476, p < .001). CONCLUSIONS In performing scoliosis surgery on CP patients, surgeons with fewer than ten years of practice experience demonstrate significantly greater average operative time and decreased mean number of levels fused, yet produce similar clinical outcomes to more experienced surgeons. LEVEL OF EVIDENCE Level III, therapeutic.BACKGROUND Series on the learning curve in spinal deformity surgery have been published, but none has addressed neuromuscular spinal deformity, comprised of arguably the most complex cases. We present the first multi-center analysis of the impact of surgeon experience on neuromuscular spinal deformity surgery. METHODS A multi-center prospective study of spinal deformity surgery for cerebral palsy (CP) with at least 2 years of follow-up provided the dataset for assessment. Surgeons were categorized into one of two groups based on their self-reported first year of practice: an experienced surgeons (ES) group included those with at least 10 years of experience at the time of surgery and a young surgeons (YS) group included those with fewer than 10 years of experience at time of surgery. Groups were compared in multiple pre-operative, operative, and post-operative outcomes. RESULTS The YS group had 8 surgeons who performed 59 surgeries; the ES group had 13 surgeons who performed 103 cases, with one surgeons cases distributed in both groups. The YS group had a greater proportion of patients with severe mental retardation (89.7% vs. 68.6%, p = .01). Duration of surgery was greater in the YS group (456 vs. 344 minutes, p < .001). The mean number of levels fused was greater in the ES group (15.9 vs. 15.6, p = .024), caused by increased variation in the upper level of fusion among the ES group. No significant differences were found between groups for estimated blood loss, length of hospitalization, or in percentage of Cobb correction. Years of experience of the operating surgeon was inversely correlated with duration of surgery (rho = -0.476, p < .001). CONCLUSIONS In performing scoliosis surgery on CP patients, surgeons with fewer than ten years of practice experience demonstrate significantly greater average operative time and decreased mean number of levels fused, yet produce similar clinical outcomes to more experienced surgeons. LEVEL OF EVIDENCE Level III, therapeutic.

Can a Novel, Low-Cost Simulation Model be Used to Teach Anterior Cruciate Ligament Graft Preparation?

Background: This study evaluated an anterior cruciate ligament (ACL) graft preparation simulation learning model for use by orthopaedic surgery trainees. Methods: A simulation model for ACL graft preparation was constructed using shoelace as graft material and a wooden graft preparation board that matched the dimensions of existing products. A 12-minute instructional video targeted at novice learners was created to accompany the simulation model. A prospective randomized controlled trial was conducted on orthopaedic surgery residents divided into 2 groups with equal distributions of postgraduate year (PGY) status. The intervention group learned ACL graft preparation via the Shoelace ACL Simulation Guide, whereas a control group viewed a standard instructional video. All participants then prepared an 8-strand ACL graft using allograft materials and were evaluated via a checklist of critical steps and a global assessment rating as provided by an expert blinded to group allocation. Participants’ preintervention and postintervention self-assessment scores were also collected. Results: Ten orthopaedic surgery residents from a single institution participated in the study, with even distributions across study groups of PGY-1, PGY-3, and PGY-4 residents. Preintervention self-assessments of knowledge and technical ability were similar between participant groups. The mean overall performance score was significantly greater in the shoelace simulation intervention group (22.6±1.5) than in the instructional video only control group (16.0±5.1) (P=0.043). Participants in the intervention group showed greater improvement in self-confidence in their technical ability than those in the control group (P=0.012). Groups demonstrated similar postintervention improvements in self-reported knowledge of ACL graft preparation (P=0.128). All participants who learned via the Shoelace ACL Simulation Guide strongly agreed that they would use the learning tool to prepare for ACL reconstruction surgery. Conclusions: A self-directed low-cost simulation model for soft tissue ACL graft preparation utilizing shoelaces resulted in improved performance metrics compared with standard video instruction. The teaching model may be incorporated easily and inexpensively into simulation curricula at other training programs. Level of Evidence: Level II—therapeutic study.

A Dedicated Orthopaedic Trauma Operating Room Improves Efficiency at a Pediatric Center

Background: Dedicated orthopaedic trauma operating rooms have improved operating room efficiency, physician schedules, and patient outcomes in adult populations. The purpose of this study was to determine if a dedicated orthopaedic trauma operating room was associated with improved patient flow and cost savings at a level-I pediatric trauma center. Methods: A retrospective analysis was performed for two 3-year intervals before and after implementation of a weekday, unbooked operating room reserved for orthopaedic trauma cases. Index procedures for 5 common fractures were investigated, including supracondylar humeral fractures, both bone forearm fractures, lateral condylar fractures, tibial fractures, and femoral fractures. To provide a control group to account for potential extrinsic changes in hospital efficiency, laparoscopic appendectomies were also analyzed. For each procedure, efficiency parameters and surgical complications, defined as unplanned reoperations, were compared between time periods. The mean cost reduction per patient was calculated on the basis of the mean daily cost of an inpatient hospital bed. Results: Of 1,469 orthopaedic procedures analyzed, 719 cases occurred before the implementation of the dedicated orthopaedic trauma operating room, and 750 cases were performed after the implementation. The frequency of after-hours procedures (5 P.M. to 7 A.M.) was reduced by 48% (p < 0.001). The mean wait time for the operating room decreased among supracondylar humeral fractures, lateral condylar fractures, and tibial fractures, whereas no significant decrease (p = 0.302) occurred among 2,076 laparoscopic appendectomy cases. The mean duration of the surgical procedure and the mean time in the operating room were not significantly affected. Across all orthopaedic procedures, the mean duration of inpatient hospitalization decreased by 5.6 hours (p < 0.001), but no significant difference occurred among appendectomies. Decreased length of stay resulted in a mean cost reduction of

Surgical Reduction and Fixation of Tibial Spine Fractures in Children: Multiple Fixation Strategies

1,251 per patient. Supracondylar humeral fracture cases performed after implementation of the dedicated orthopaedic trauma operating room had fewer surgical complications (p = 0.018). No difference in complication rate was detected among the other orthopaedic procedures. Conclusions: A dedicated orthopaedic trauma operating room in a pediatric trauma center was associated with fewer after-hours procedures, decreased wait time to the surgical procedure, reduced length of hospitalization, and decreased cost.

Flexion-Type Supracondylar Humeral Fractures: Ulnar Nerve Injury Increases Risk of Open Reduction

A tibial spine fracture is an osseous avulsion of the anterior cruciate ligament (ACL) from its attachment on the intercondylar tibial eminence. Most commonly affecting the immature skeletal systems of children between 8 and 14 years old, tibial spine fractures are frequently regarded as the pediatric equivalent to adult midsubstance ACL injuries. While all nondisplaced and selected partially displaced fractures can be treated nonoperatively, surgical fixation is most frequently used for completely displaced tibial spine fractures. The goals of surgery include osseous union, restoration of knee stability, return to function, treatment of associated injuries, and restoration of the range of motion. Current evidence has demonstrated equivalent outcomes for open and arthroscopic reduction strategies, as well as for screw-based and suture-based fixation techniques. The surgeon should be prepared to offer a multitude of fixation techniques based on intraoperative findings that will provide stable anatomic reduction, including, for instance, the use of suture-based fixation in comminuted fragments. This video article demonstrates an arthroscopic procedure to repair a tibial spine fracture, including 3 methods of fixation, in the following major steps: (1) preoperative planning, (2) patient positioning and surgical exposure, (3) evacuation of the hemarthrosis, (4) diagnostic arthroscopy, (5) preparation of the fracture fragment, (6) reduction of the fracture fragment, (7) fixation option 1: screw fixation, (8) fixation option 2: suture anchor, (9) fixation option 3: suture, and (10) dynamic assessment of stability and closure. Excellent functional outcomes using this procedure have been documented and, with appropriate postoperative care that includes range-of-motion exercises beginning as early as 1 to 2 weeks postoperatively, patients are expected to recover function and to resume a normal activity level. Complications, including nonunion, malunion, and arthrofibrosis, can be reduced when patients with completely displaced tibial spine fractures are treated with surgical management.