Perspective on robotic spine surgery: Who’s doing the thinking?

Background: Robotic assisted (RA) spine surgery was developed to reduce the morbidity for misplaced thoracolumbar (TL) pedicle screws (PS) resulting in neurovascular injuries, dural fistulas, and/or visceral/other injuries. RA is gaining the attention of spine surgeons to optimize the placement of TL PSs, and to do this more safely/effectively versus utilizing stereotactic navigation alone, or predominantly free hand (FH) techniques. However, little attention is being focused on whether a significant number of these TL RA instrumented fusions are necessary. Methods: RA spine surgery has been developed to improve the safety, efficacy, and accuracy of minimally invasive TL versus open FH PS placement. Results: Theoretical benefits of RA spine surgery include; enhanced accuracy of screw placement, fewer complications, less radiation exposure, smaller incisions, to minimize blood loss, reduce infection rates, shorten operative times, reduce postoperative recovery periods, and shorten lengths of stay. Cons of RA include; increased cost, increased morbidity with steep learning curves, robotic failures of registration, more soft tissue injuries, lateral skiving of drill guides, displacement of robotic arms impacting accurate PS placement, higher reoperation rates, and potential loss of accuracy with motion versus FH techniques. Notably, insufficient attention has been focused on the necessity for performing many of these TL PS instrumented fusions in the first place. Conclusion: RA spinal surgery is still in its infancy, and comparison of RA versus FH techniques for TL PS placement demonstrates several potential pros, but also multiple cons. Further, more attention must be focused on whether many of these TL PS instrumented procedures are even warranted.

Post-operative Anemia After Major Surgery: a Brief Review

Purpose of Review Anemia is a very common complication in the post-operative period. Post-operative anemia is associated with poor outcomes including but not limited to infections, increased length of stay, circulatory overload, and mortality. The strategy of patient blood management focuses on three pillars that include the detection and treatment of pre-operative anemia; reduction of peri-operative blood loss; and harnessing and optimizing the patient-specific physiological reserve of anemia. Recent Findings Multiple studies in surgical patients have been conducted to study various methods of management of post-operative anemia. Recent advances in surgical techniques have also been studied to minimize blood loss. There is a widespread consensus on the use of intravenous iron in hospitalized post-operative patients after major surgery. Summary We discuss the most common causes of post-operative anemia and management focusing on measures to reduce blood loss and measures to increase red blood cell (RBC) mass. In this brief review, we present updates from the most relevant articles in the past 5 years and include updates from the 2018 international consensus statement on the management of post-operative anemia after major surgical procedures.

Can We Create an Arteriovenous Fistula for Hemodialysis through 0.5–1.0 cm Incision without Using Vascular Clamps?

Background A native arteriovenous fistula (AVF) is a gold standard for renal replacement therapy, where regular hemodialysis is the mainstay of survival in the majority of patients suffering from end-stage renal disease. Appropriate vascular clamps are routinely used to occlude an artery and a vein before an arteriotomy or a venotomy is done to prevent blood loss and have a clear field and an ease of anastomosis. The title makes one wonder, is it then possible to create an AVF without using vascular clamps? And through incisions as small as 0.5to 1.0 cm? This is made possible by a very simple new technique, presented here, that helps to occlude vessels to create an AVF through minimal access, and minimize blood loss and postoperative pain. Material and Method Total 622 AVFs were created between 1998 and 2019. With regular forceps or an AVF platform (design given), an AVF was created without using a vascular clamp. Total 321 cases were operated with 0.5 to 1.0 cm and 215 cases within 1.5 cm skin incision approach. Results There were ~85% successful functional fistulas. The blood loss was negligible, and only one in three required pain killer in postoperative period. Conclusion A simple new technique described here makes it possible to create a functional AVF through a small incision, without using vascular clamps.

Tranexamic Acid in Foot and Ankle Surgery: A Topical Review and Value Analysis

Tranexamic acid (TXA) has become a commonly used perioperative intervention in total joint arthroplasty, shoulder and knee arthroscopy, and spinal procedures in order to minimize blood loss, hematoma formation, hemarthrosis, and wound healing complications. There is a potential role for TXA use in foot and ankle procedures, with limited studies suggesting a potential benefit in minimizing postoperative wound complications and blood loss without an increased risk of thromboembolic events. In light of the profound clinical and financial impact of TXA use in other orthopaedic subspecialties and the early successes in foot and ankle surgery, we aim to provide more information about TXA and its use in foot and ankle surgery. Therefore, the purpose of this review is to perform a comprehensive literature review on the topic of TXA use in foot and ankle procedures in order to describe the pertinent available literature on the use of TXA in orthopaedic surgery and its implications specifically in foot and ankle surgery. It is our aim to identify potential benefits and shortcomings in the available evidence on TXA use for foot and ankle surgery in hopes to (1) best inform foot and ankle surgeons where beneficial and safe and (2) inspire further research on this topic as it relates to clinical management for foot and ankle patients. Levels of Evidence: Level IV

Impact of ferric carboxymaltose in patient blood management in Portuguese hospitals

Background The use of transfusions leads to excessive blood consumption, implying risks such as infections and immunological reactions, so it should be used only when strictly necessary. Patient Blood Management (PBM) aims to minimize the use of allogeneic blood and improve clinical outcomes, with better cost-effectiveness, using three essential points: improving hematopoiesis, minimize blood loss in and optimize the hemoglobin reserves of each patient. The aim of this work is to assess the preoperative haemoglobin optimization using ferric carboxymaltose as part of PBM implementation, in elective orthopaedic, cardiac and colorectal surgery in Portuguese hospitals. Methods This is an observational study materialized in a retrospective and multicenter cohort with data collection from medical records. The population and sample will be patients over 18 years from elective orthopaedic, cardiac and colorectal surgeries, treated according with local standards before PBM implementation were assigned to the pre-PBM cohort and patients after PBM implementation with ferric carboxymaltose to preoperative haemoglobin optimization to the PBM cohort. The criteria for selecting hospitals will be the implementation of PBM during the study period. Expected Results Based on a previous review, it is expected that the results of the use of ferric carboxymaltose to correct iron deficiency anaemia for preoperative haemoglobin optimization will contribute positively to reducing the number of transfusions, the length of hospital stays and will have a direct impact on economic results. Conclusions The use of ferric carboxymaltose and other ferric compounds, as part of PBM program, has demonstrated a positive impact on patients' outcomes (morbility and mortality), adverse events and on economic results. This study might show that clinical guidelines and programs like PBM are a major contribution not just for hemovigilance and blood safety but also for patient safety and health quality. Key messages This work is focused on Portuguese hospitals and aims to assess the impact of ferric carboxymaltose and its benefit on PBM strategy. Specially this study intends to conduct the assessment on health outcomes and costs.