Patient Safety in Surgery

Minimally invasive surgical treatment of pelvic trauma requires a significant level of surgical training and technical expertise. Novel imaging and navigation technologies have always driven surgical technique, and with head-mounted displays being commercially available nowadays, the assessment of such Augmented Reality (AR) devices in a specific surgical setting is appropriate. In this ex-vivo feasibility study, an AR-based surgical navigation system was assessed in a specific clinical scenario with standard pelvic and acetabular screw pathways. The system has the following components: an optical-see-through Head Mounted Display, a specifically designed modular AR software, and surgical tool tracking using pose estimation with synthetic square markers. The success rate for entry point navigation was 93.8%, the overall translational deviation of drill pathways was 3.99 ± 1.77 mm, and the overall rotational deviation of drill pathways was 4.3 ± 1.8°. There was no relevant theoretic screw perforation, as shown by 88.7% Grade 0–1 and 100% Grade 0–2 rating in our pelvic screw perforation score. Regarding screw length, 103 ± 8% of the planned pathway length could be realized successfully. The novel innovative system assessed in this experimental study provided proof-of-concept for the feasibility of percutaneous screw placement in the pelvis and, thus, could easily be adapted to a specific clinical scenario. The system showed comparable performance with other computer-aided solutions while providing specific advantages such as true 3D vision without intraoperative radiation; however, it needs further improvement and must still undergo regulatory body approval. Future endeavors include intraoperative registration and optimized tool tracking.

Z-effect and reverse Z-effect are complications that arise from the surgical treatment of pertrochanteric fractures of the femur with proximal femoral nails (PFN) comprising two interlocking head screws. Such complications are induced by the migration of screws in opposite directions, which may lead to failure of the osteosynthesis. The paper describes three cases of pertrochanteric fractures that were treated with PFN with two interlocking screws that evolved to either Z-effect or reverse Z-effect. Literature-based explanations for this phenomenon are provided together with recommendations of how to avoid such complications. Although intramedullary fixation is an established method of treatment of femoral intertrochanteric and subtrochanteric fractures, the evolution of the procedure may include complications associated with the migration of the interlocking head screws. The occurrence of Z-effect and reverse Z-effect has not been completely elucidated, but the main causes of such complications are probably fracture fixation in varus position, severe medial comminution, inappropriate entry point of the nail and poor bone quality.

Acute myocardial infarction (AMI) is an uncommon but fatal complication among patients undergoing elective spinal fusion surgery (SF), total hip arthroplasty (THA), and total knee arthroplasty (TKA). Our objective was to estimate the incidence of AMI among adults undergoing elective SF, THA, and TKA in different post-operative risk windows and characterize high-risk sub-populations in the United States. A retrospective cohort study was conducted using data from a longitudinal electronic healthcare record (EHR) database from January 1, 2007 to June 30, 2018. ICD codes were used to identify SF, THA, TKA, AMI, and selected clinical characteristics. Incidence proportions (IPs) and 95% confidence intervals were estimated in the following risk windows: index hospitalization, ≤ 30, ≤ 90, ≤ 180, and ≤ 365 days post-operation. A total of 67,533 SF patients, 87,572 THA patients, and 167,480 TKA patients were eligible for the study. The IP of AMI after SF, THA, and TKA ranged from 0.36, 0.28, and 0.25% during index hospitalization to 1.05, 0.93, and 0.85% ≤ 365 days post-operation, respectively. The IP of AMI was higher among patients who were older, male, with longer hospital stays, had a history of AMI, and had a history of diabetes. The IP of post-operative AMI was generally highest among the SF cohort compared to the THA and TKA cohorts. Additionally, potential high-risk populations were identified. Future studies in this area are warranted to confirm these findings via improved confounder control and to identify effect measure modifiers.

Surgeons have a range of materials to choose from to complete wound closure, yet surprisingly very little is still known about the body’s immune response to the suture materials in current use. The growing literature of adverse suture material reactions provided the objective of this study, to use in vitro assays to quantify levels of inflammation produced by seven commonly used suture materials in surgical procedures. Human monocyte/macrophage THP-1 cells were exposed to suture materials for 1, 3 and 5 days. Gene expression and protein secretion of six inflammatory cytokines and two cell surface markers were assessed using qPCR and ELISA respectively, with LPS exposure providing a positive control. Furthermore, a IL-1β/IL-1RA marker ratio was assessed to determine the balance between pro-/anti-inflammatory expression. The findings from our in vitro study suggest that four commonly used suture materials cause upregulation of pro-inflammatory markers indicative of an early foreign body reaction, with no balance from anti-inflammatory markers. As prolonged early pro-inflammation is known to produce delayed wound healing responses, the knowledge produced from this study has potential to improve informed surgical decision making and patient safety. This work has the capability to reduce suture-related adverse immune reactions, and therefore positively affect patient outcomes.

The femoral neck fracture is one of the most common fractures in the elderly. A variety of methods and approaches are used to treat it. Total hip arthroplasty is a preferred approach in independent, mobile, elderly patients, given its more favorable long-term outcome. Our hypothesis is that the direct anterior approach in geriatric trauma patients has a lower dislocation-rate with the advantage of early recovery due to a muscle sparing approach and therefore early possible full weight-bearing. Patients were retrospectively sought who suffered a femoral neck fracture from 2008 to 2013. All patients were treated through a direct anterior approach and using the same brand of implants. Medical history, standardized physical exam, conventional pelvic plain and axial hip x-rays, Harris Hip Score, Merle D'Aubigné and Postel and SF-36 were assessed. Eighty-six patients were included in the study with a mean age of seventy-five years. The mortality rate was 16.7 %. Complications were encountered in nineteen patients (22.0 %) who needed operative revision and one postoperative complication (1.2 %) which could be handled conservatively. There were five intraoperative complications (5.8 %), two dislocations (2.3 %), one aseptic loosening in a non-cemented stem (1.2 %), six periprosthetic fractures in non-cemented stems (6.9 %), one displacement of a non-cemented cup (1.2 %), two early infections (2.3 %) and three hematomas (3.5 %) recorded. Although the direct anterior approach is associated with a rather long learning curve we have found it to preserve the soft-tissues with no injury to abductors. It therefore shows an early advantage in elderly patients in terms of early recovery and therefore early possible full weight-bearing. Fracture treatment with dual mobility cups might lead to lower dislocation rates, but are associated with higher costs. Due to higher complication rates in non-cemented versus cemented shafts, we have changed our practice towards favoring cemented femoral stems in patients with suspected or manifest osteoporosis.

Using crude mortality and morbidity rates for comparing outcomes can be misleading. The aim of the present study was to compare the outcome of various surgical modalities without and with risk adjustment using Physiologic and Operative Severity Scoring for the enUmeration of Mortality and morbidity (POSSUM) score in cases of ileal perforations. Prospective study on 125 patients of ileal perforations. Resection anastamosis (Group I) was done in 38 patients, primary repair (Group II) in 42 patients and 45 patients had an ileostomy (Group III). The disease severity was assessed in all patients using POSSUM score. The odds of death without and with risk adjustment using POSSUM mortality score were calculated for all groups Seventeen patients (14%) patients died and 99 (79%) developed postoperative complications. Using crude mortality rates Group I appeared to be the best treatment option with only 2 (5%) deaths followed by Group II with 5 (12%) deaths where as Group III had the worst outcome with 10 deaths (22%). However, Group III (ileostomy) patients had higher mean POSSUM mortality and morbidity score (55.55%, 91.33%) than Group I (28%, 75.26%) and Group II (27%, 73.59%). Taking Group I as the reference (odds ratio, OR1) odds of death were greatest in Group III (OR 5.14, p = 0.043) followed by Group II (OR 2.43, p = 0.306). With risk adjustment using POSSUM mortality score the odds of death decreased in Group III (OR 1.16 p = 0.875). For the whole group, there was a significant association between the POSSUM score and postoperative complications and deaths. Mean POSSUM mortality and morbidity score of those who died (63.40 vs.33.68, p = 0.001) and developed complications (66.32 vs.84.20, p = 0.001) was significantly higher. For every percent increase in severity score the risk of postoperative complications and death increased by 1.10 (p = 0.001) and1.06 (p = 0.001) respectively. Despite ileostomy patients having highest crude mortality and complication rates, after risk adjustment it was equally safe. Severity of the disease rather than the surgical option had a significant impact on the outcome in patients with ileal perforations.

Hospital length of stay (HLOS) is a commonly used measure of hospital quality and is influenced by clinical and non-clinical factors. To reduce HLOS, it is key to identify factors placing patients at increased risk of lengthy HLOS and discharge delays. This was a retrospective cohort study of patients age ≥ 18 admitted to four level 1 trauma centers between 1/1/2015 and 3/31/2018 with traumatic brain injury (TBI). The primary outcome was discharge delay, defined as discharge ≥24 h after case management notes indicated the patient was ready for discharge. The independent variables of interest were primary insurance provider and discharge destination. Chi-square, Fisher exact, and unadjusted and adjusted logistic regression analyses were used to assess associations between discharge delay and the two primary independent variables, as well as other patient demographic and clinical characteristics. Complications developing during the delay period were also examined. A total of 1543 patients with TBI were included. The median age was 61 years, and the median HLOS was 5 days. Approximately half of patients were discharged home (54%). The most common insurance providers were Medicare (35%) and commercial/private (35%). Two-hundred ten (14%) patients experienced a discharge delay. The median delay period was 3 days, and the most common reasons for delay were insurance authorization (52%) and lack of accepting bed (41%). Compared to being discharged home, patients discharged to a skilled nursing facility (adjusted odds ratio (AOR) = 10.35) or intermediate care facility (AOR = 10.64) had the highest odds of discharge delay. Compared to Medicare patients, uninsured/self-pay patients (AOR = 2.98) and those with Medicaid (AOR = 2.83) or commercial/private insurance (AOR = 2.22) had higher odds of delay. Thirty-two patients (15% of those delayed) experienced at least one complication during the delay, some of which were clinically severe. A substantial portion of TBI patients in this study experienced discharge delays, and discharge destination and primary insurance provider were significant drivers of these delays. Evaluation of a facility’s quality of care should consider the specific causes of these delays.

Gall bladder perforation, gallstone spillage and loss are commonly reported from Laparoscopic Cholecystectomy (LC). Though rare, lost gallstones can cause a variety of complications presenting variably from within 1 month to 20 years postoperatively. Our objective was to investigate knowledge and practices of surgeons and surgical residents regarding spilled gallstones lost during laparoscopic cholecystectomy. An observational, cross-sectional survey, using a questionnaire based on 13 self-answered close-ended questions, was conducted at 6 different post-graduate centers in Karachi, Pakistan. Of the 82 participants, 23 (28%) were consultant surgeons while 59 (72%) were general surgery residents. 86% of participants were aware that stones lost during LC can cause complications. Out of the 18 reported complications presented, only 20% participants identified more than 8 complications for which they can consider lost gallstones causal. 28% of participants weren’t aware about the expected postoperative duration for presentation of complications. Only 15% of our participants expected complications beyond 5 years of the procedure. 72% of participants will not convert to open cholecystectomy to retrieve lost gallstones. While 88% of participants agreed that lost gallstones should be documented in operative notes, only 70% reported that it’s actually done in practice. 55% of participants agreed to have possibility of lost gallstones as part of the informed consent but in practice it’s included according to only 31% of participants. 68% of participants believe that patients should be informed if gallstones are lost but in actual practice only 41% participants inform patients when gallstones are lost during procedure. We conclude that there is a dearth of awareness regarding diversity of complications from lost gallstones and about their variable postoperative duration of presentation. The practices involving lost gallstones management, documentation and patient information were found to vary widely. Proper awareness is imperative as it may compel surgeons to undertake all possible measures to retrieve spilled gallstones and progress towards better and standardized practices in managing lost gallstones.