Learning Curves of Robotic Spine Surgery in a System Lack of Active Perception: Potential Roles of Teamwork and Unmet Needs

Background: The aim of this study was to investigate the learning curve of robotic spine surgery quantitatively with the well-described power law of practice.Methods: Kaohsiung Medical University Hospital set up a robotic spine surgery team by the neurosurgery department in 2013 and the orthopedic department joined the well-established team in 2014. A total of 150 cases and 841 transpedicular screws were enrolled into 3 groups: the first 50 cases performed by neurosurgeons, the first 50 cases by orthopedic surgeons, and 50 cases by neurosurgeons after the orthopedic surgeons joined the team. The time per screw and accuracy by each group and individual surgeon were analyzed.Results: The time per screw for each group was 9.56±4.19, 7.29±3.64, and 8.74±5.77 minutes respectively. The accuracy was 99.6% (253/254), 99.5% (361/363), and 99.1% (222/224), respectively. The first group took significantly more time per screw, but without significance on the nonlinear parallelism test. Analysis of 5 surgeons and their first 10 cases of short segment surgery showed the time per screw by each surgeon was 12.28±5.21, 6.38±1.54, 8.68±3.10, 6.33±1.90, and 6.73±1.81 minutes. The first surgeon who initiated the robotic spine surgery took significantly more time per screw and the nonlinear parallelism test also revealed only the first surgeon had a steeper learning curve. Conclusions: This is the first study to demonstrate that differences of learning curves between individual surgeons and teams. The roles of teamwork and the unmet needs due to lack of active perception are discussed.

Incidental Diagnosis of Metastatic Prostate Cancer Post-Inguinal Hernia Repair

This report discusses the case of an 83-year-old male who was incidentally found to have a diagnosis of metastatic prostate cancer on pathology from elective inguinal hernia repair. The medical record, radiology, operative reports, and pathology of the patient were reviewed and a literature search was subsequently performed. A new cancer diagnosis is a very rare finding during routine hernia surgery. Moreover, the decision of whether to send a hernia sac for routine pathology is often dependent on individual surgeon practices and institutional guidelines. However, this case demonstrates the potential for an unexpected finding on routine pathology to significantly alter the clinical course of a patient’s care as the patient subsequently underwent both medical and palliative surgical treatment for prostate cancer.

Unexpected high rate of revision of a modern cemented fixed bearing modular posterior-stabilized knee arthroplasty

Aims To establish our early clinical results of a new total knee arthroplasty (TKA) tibial component introduced in 2013 and compare it to other designs in use at our hospital during the same period. Methods This is a retrospective study of 166 (154 patients) consecutive cemented, fixed bearing, posterior-stabilized (PS) TKAs (ATTUNE) at one hospital performed by five surgeons. These were compared with a reference cohort of 511 knees (470 patients) of other designs (seven manufacturers) performed at the same hospital by the same surgeons. There were no significant differences in age, sex, BMI, or follow-up times between the two cohorts. The primary outcome was revision performed or pending. Results In total, 19 (11.5%) ATTUNE study TKAs have been revised at a mean 30.3 months (SD 15), and loosening of the tibial component was seen in 17 of these (90%). Revision is pending in 12 (7%) knees. There was no difference between the 31 knees revised or with revision pending and the remaining 135 study knees in terms of patient characteristics, type of bone cement (p = 0.988), or individual surgeon (p = 0.550). In the reference cohort, there were significantly fewer knees revised (n = 13, 2.6%) and with revision pending (n = 8, 1.5%) (both p < 0.001), and only two had loosening of the tibial component as the reason for revision. Conclusion This new TKA design had an unexpectedly high early rate of revision compared with our reference cohort of TKAs. Debonding of the tibial component was the most common reason for failure. Additional longer-term follow-up studies of this specific component and techniques for implantation are warranted. The version of the ATTUNE tibial component implanted in this study has undergone modifications by the manufacturer. Cite this article: Bone Joint J 2021;103-B(6 Supple A):137–144.

292 Publication of Individual Surgeon Outcomes Data: The Wishes of Orthopaedic Patients and Their Surgeons

Background The Paterson report recommended increased release of individual surgeon data to the public. There is limited evidence in the literature about patients’ or orthopaedic surgeons’ wishes regarding release of such data to the public. Method We surveyed 80 joint replacement patients and 41 orthopaedic surgeons to determine their wishes regarding collection and release of individual surgeon data to the public. Results Patients expected more current monitoring of data than actually occurs. Of the patients, 95% wanted data to be available describing surgeon experience, length of stay and complications. Regarding currently available data, 50% of patients who were aware of it were likely to view it on the internet. Surgeons were aware of the data available, but 80% did not think it was accurate. Surgeons did not think this data improved standards, that it negatively affected innovation (61%) and training (76%) and led to risk averse behaviour (61%). Surgeons wanted a minimal data set accurately presented and risk adjusted. Conclusions We recommend an agreed minimum dataset of good quality data is collected and discussed in clinical governance sessions. It can then be released to the public with explanatory notes.

Does Localization Technique Matter for Non-palpable Breast Cancers?

Background There are several techniques for localization of non-palpable breast tumors, but comparisons of these techniques in terms of margin positivity and volume of tissue resected are lacking. Methods Between 2011-2013 and 2016-2018, 2 randomized controlled trials involving 10 centers across the United States accrued 631 patients with stage 0-3 breast cancer, all of whom underwent breast conserving surgery. Of these, 522 had residual non-palpable tumors for which localization was required. The localization technique was left to the discretion of the individual surgeon. We compared margin positivity and volume of tissue resected between various localization techniques. Results The majority of the patients (n = 465; 89.1%) had wire localization (WL), 50 (9.6%) had radioactive seed (RS) localization, and 7 (1.3%) had Savi Scout (SS) localization. On bivariate analysis, there was no difference in terms of margin positivity (37.8% vs. 28.0% vs. 28.6%, P = .339) nor re-excision rates (13.3% vs. 12.0% vs. 14.3%, P = .961) for the WL, RS, and SS groups, respectively. Further, the volume of tissue removed was not significantly different between the 3 groups (71.9 cm3 vs. 55.8 cm3 vs. 86.6 cm3 for the WL, RS, and SS groups, respectively, P = .340). On multivariate analysis, margin status was affected by tumor size (OR = 1.336; 95% CI: 1.148-1.554, P<.001) but not by type of localization ( P = .670). Conclusions While there are a number of methods for tumor localization, choice of technique does not seem to influence volume of tissue resected nor margin status.

Institution-Specific Strategies for Head and Neck Oncology Triage During the COVID-19 Pandemic

Background: This work seeks to better understand the triage strategies employed by head and neck oncologic surgical divisions during the initial phases of the coronavirus 2019 (COVID-19) outbreak. Methods: Thirty-six American head and neck surgical oncology practices responded to questions regarding the triage strategies employed from March to May 2020. Results: Of the programs surveyed, 11 (31%) had official department or hospital-specific guidelines for mitigating care delays and determining which surgical cases could proceed. Seventeen (47%) programs left the decision to proceed with surgery to individual surgeon discretion. Five (14%) programs employed committee review, and 7 (19%) used chairman review systems to grant permission for surgery. Every program surveyed, including multiple in COVID-19 outbreak epicenters, continued to perform complex head and neck cancer resections with free flap reconstruction. Conclusions: During the initial phases of the COVID-19 pandemic experience in the United States, head and neck surgical oncology divisions largely eschewed formal triage policies and favored practices that allowed individual surgeons discretion in the decision whether or not to operate. Better understanding the shortcomings of such an approach could help mitigate care delays and improve oncologic outcomes during future outbreaks of COVID-19 and other resource-limiting events. Level of Evidence: 4.