Purpose

Students attend operating room sessions throughout their medical school training and are often given the opportunity to scrub and assist during the surgery. Many students have no or very little formal teaching in operating room etiquette, which leads to last minute on the job training from operating room staff. This study aimed to identify if there was any difference between the students knowledge, technique and competency in operating room etiquette skills between two groups of students who received different methods of teaching.

According to Webster's Dictionary, efficiency is defined as the capacity to produce desired results with a minimal expenditure of energy, money, time, and materials. For a surgeon performing an operative procedure this would mean “skillfulness in avoiding wasted time and effort.” (. www.webster-dictionary.org. ) The essential ingredient to becoming efficient is to promote a culture of efficiency. There are 10 elements: 1) proactive surgeon perspective; 2) effective utilization of preoperative holding area; 3) preoperative planning / templating; 4) development of preference cards; 5) operating room set-up protocols; 6) operating room team concept; 7) streamlined instrument sets; 8) consistent operative workflow; 9) standardised closure / dressings; and 10) prompt and meticulous room turnover. Efficient performance of an operative procedure requires skillfulness in avoiding wasted time and effort. Perioperative efficiencies are optimised by development of “swing,” “flip,” or “double occupancy” criteria, understanding of timing of when to initiate the anesthetic block for the next case, skin closure routine by physician assistant/nurse practitioner/private scrub, and marking the operative site of your first two patients upon arrival to the hospital or surgery center. Utilise a pro-active approach to prepare case carts the day before surgery. The operating room team turns over their own rooms, with a “clean as you go” mentality. Develop a formalised communication process for patient flow issues, such as real-time push-to-talk group calling phones. Determine in advance the number of instrument sets required for the day's caseload to mitigate flash sterilization and decrease room turnover time. The goal of the surgeon is to be out of the operating room for 5 minutes in between cases before the next incision, utilizing that time to enter orders, communicate with the family, dictate, and mark the operative site of the patient who will follow the one in the case about to start. Implant selection can help if consistent. Everyone must know the instrument trays including surgeon, scrubs, and nurses. Minimise both the number of trays and the redundancy of instrumentation. Templating should be done in advance of the day of surgery. Keep your surgery consistent and always deliver your best product. The workflow for inpatient and outpatient surgeries should be the same: same implant, same approach, and same closure. The culture of efficiency requires buy-in by all involved in the operative procedure. Every one entering the operating theatre should have proper body coverage – no hair visible, no nose visible. There should be a strict limit to needless activity: minimum opening of doors, no changing of personnel during an operation, and use of intercom/telephone to request equipment. As the surgeon and the team begin to embrace efficiency, surgical times will decrease. Multiple studies have demonstrated that increased surgical time is associated with a higher incidence of infection. This is secondary to time-dependent contamination of the surgical wound and field. The take home message is to develop and embrace efficiency. Operating room efficiency is the product of multiple factors including preoperative preparation, skilled anesthesia team, motivated operating room staff, choreographed surgery, and well-designed instrumentation. The surgeon is the captain of the ship and the staff follows his or her lead. Your operating room days will flow smoothly. Your operations will proceed with minimal stress. You will spend less time drinking coffee between cases and have more free time at the end of the day. However, most importantly, you will deliver a quality product to your patient

Background. Intraoperative blood loss is a known potential complication of total knee arthroplasty (TKA). Tranexamic acid (TXA) has been shown to reduce intraoperative blood loss and postoperative transfusion in patients undergoing TKA. While there are numerous studies demonstrating the efficacy of intravenous and topical TXA in patients undergoing TKA, there are comparatively few demonstrating the effectiveness and appropriate dosing recommendations of oral formulations. Methods. A retrospective cohort study of 2230 TKA procedures at a single institution identified 3 treatment cohorts: patients undergoing TKA without the use of TXA (no-OTA, n=968), patients undergoing TKA with administration of a single-dose of oral TXA (single-dose OTA, n=164), and patients undergoing TKR with administration of preoperative and postoperative oral TXA (two-dose OTA, n=1098). The primary outcome was transfusion rate. Secondary outcomes included maximum postoperative decline in hemoglobin, number of blood units transfused, length of hospital stay, total drain output, cell salvage volume, and operating room time. Results. Transfusion rates decreased from 24.1% in the no-OTA group to 13.6% in the single-dose OTA group (p<0.001) and 11.1% in the two-dose OTA group (p<0.001), with no significant difference in transfusion rates between single- and two-dose OTA groups (p=0.357). Operating room time was reduced from 154 minutes in the no-OTA group to 144 minutes in the one-dose OTA group and 144 minutes in the two-dose OTA group (p<0.01). Additionally, maximum postoperative decline in hemoglobin was reduced from 4.3 g/dL in the no-OTA group to 3.5 g/dL in the single-dose OTA group (p<0.01) and 3.4 g/dL in the two-dose OTA group (p<0.01), without a significant difference between the single- and two-dose regimens (p=0.233). Conclusions. OTA reduces transfusions and operating room time, with the potential advantages of greater ease of administration and improved cost effectiveness relative to other routes of administration. Further study such as a randomized clinical trial is needed to verify the effectiveness of OTA and further optimize dosing regimens in the TKA setting. Level of Evidence. Therapeutic Level III

Trainees experience significant stress in the operating room, with potentially adverse effects on performance and learning. Psychological resilience explains why some individuals excel despite significant stress, meeting challenges with optimism and flexibility. The purpose of this study was to explore the relationships between trainee resilience, intraoperative stress, and desire to leave residency training. Qualitative focus groups and a literature review were used to develop a new instrument to assess Surgical TRainee Experiences of StresS in the Operating Room (STRESSOR). STRESSOR was used in a survey of Canadian surgical residents to assess trainee stress. Resiliency was measured using the 10-item Connor-Davidson Resiliency Scale (CD-RISC-10). The survey was distributed nationally and 171 responses were collected for a 36% response rate. The greatest sources of intraoperative stress were time pressure, attending temperament, and being interrupted by a pager. The STRESSOR instrument had strong reliability (Cronbach's α=0.92) and demonstrated good construct validity using confirmatory factor analysis. The mean CD-RISC-10 score was 28.8, which is similar to that of Canadian medical students. Resilience was protective against intraoperative stress (R2=0.16, p<0.001). Residents with higher stress or lower resilience were more likely to have seriously considered leaving their training program (Spearman's rho = 0.42, p<0.001). Screening for resilience may assist in selecting trainees who are better able to manage stress during surgery and reduce resident attrition. Resiliency training may help learners manage the high stress environment of the operating room, potentially improving surgical performance and learning in the next generation of surgeons

Knee arthroscopy with meniscectomy is the third most common Orthopaedic surgery performed after TKA and THA, comprising up to 16.6% of all procedures. The efficiency of Orthopaedic care delivery with respect to waiting times and systemic costs is extremely concerning. Canadian Orthopaedic patients experience the longest wait times of any G7 country, yet perioperative surgical care constitutes a significant portion of a hospital's budget.

In-Office Needle Arthroscopy (IONA) is an emerging technology that has been primarily studied as a diagnostic tool. Recent evidence shows that it is a cost-effective alternative to hospital- and community-based MRI with comparable accuracy. Recent procedure guides detailing IONA medial meniscectomy suggest a potential node for OR diversion. Given the high case volume of knee arthroscopy as well as the potential amenability to be diverted away from the OR to the office setting, IONA has the potential to generate considerable improvements in healthcare system efficiency with respect to throughput and cost savings. As such, the purpose of this study is to investigate the cost savings and impact on waiting times on a mid-sized Canadian community hospital if IONA is offered as an alternative to traditional operating room (OR) arthroscopy for medial meniscal tears.

In order to develop a comprehensive understanding and accurate representation of the quantifiable operations involved in the current state for medial meniscus tear care, process mapping was performed that describes the journey of a patient from when they present with knee pain to their general practitioner until case resolution. This technique was then repeated to create a second process map describing the hypothetical proposed state whereby OR diversion may be conducted utilizing IONA. Once the respective process maps for each state were determined, each process map was translated into a Dupont decision tree. In order to accurately determine the total number of patients which would be eligible for this care pathway at our institution, the OR booking scheduling for arthroscopy and meniscectomy/repair over a four year time period (2016-2020) were reviewed. A sensitivity analysis was performed to examine the effect of the number of patients who select IONA over meniscectomy and the number of revision meniscectomies after IONA on 1) the profit and profit margin determined by the MCS-Dupont financial model and 2) the throughput (percentage and number) determined by the MCS-throughput model.

Based on historic data at our institution, an average of 198 patients (SD 31) underwent either a meniscectomy or repair from years 2016-2020. Revenue for both states was similar (p = .22), with the current state revenue being $ 248,555.99 (standard deviation $ 39,005.43) and proposed state of $ 249,223.86 (SD $ 39,188.73). However, the reduction in expenses was significant (p < .0001) at 5.15%, with expenses in the current state being $ 281,415.23 (SD $ 44,157.80) and proposed state of $ 266,912.68 (SD $ 42,093.19), representing $14,502.95 in savings. Accordingly, profit improvement was also significant (p < .0001) at 46.2%, with current state profit being $ (32,859.24) (SD $ 5,153.49) and proposed state being $ (17,678.82) (SD $ 2,921.28). The addition of IONA into the care pathway of the proposed state produced an average improvement in throughput of 42 patients (SD 7), representing a 21.2% reduction in the number of patients that require an OR procedure. Financial sensitivity analysis revealed that the proposed state profit was higher than the current state profit if as few as 10% of patients select IONA, with the maximum revision rate needing to remain below 40% to achieve improved profits.

The most important finding from this study is that IONA is a cost-effective alternative to traditional surgical arthroscopy for medial meniscus meniscectomy. Importantly, IONA can also be used as a diagnostic procedure. It is shown to be a cost-effective alternative to MRI with similar diagnostic accuracy. The role of IONA as a joint diagnostic-therapeutic tool could positively impact MRI waiting times and MRI/MRA costs, and further reduce indirect costs to society. Given the well-established benefit of early meniscus treatment, accelerating both diagnosis and therapy is bound to result in positive effects.

Introduction

One method of surgical site infection prevention is lowering intraoperative environmental contamination. We sought to evaluate our hospitals operating room (OR) contamination rates and compare it to the remainder of the hospital. We tested environmental contamination in preoperative, intraoperative and postoperative settings of a total joint arthroplasty patient.

In computer assisted orthopaedic surgery, intraoperative registration is commonly performed by fitting features acquired from the exposed bone surface to a preoperative virtual model of the bone geometry. In cases where the acquired spatial measurements are unreliable or have been inappropriately chosen, the registration result can degenerate. Current performance indicators, such as the root mean squared (RMS) error and the spatial distribution of the registered feature errors may not be sufficient to warn the surgeon of such a case.

In this study, statistical analysis is applied to the registration outcomes of perturbed variants of a collected point set. In this way, it is possible to assess the ability of the original set to represent the underlying surface, taking into account the distribution of the points as well as errors introduced during the acquisition process. Confidence measures are calculated to predict the reliability of the original registration result and therefore the robustness of the point set itself.

For proof of concept, this method has been tested in simulation with a CT-generated tibia model. The algorithm was used to identify the 10 best performing of a population of 1000 randomly generated point sets. All registration outcomes produced by these point sets were found to be superior to those resulting from sets of the same size produced manually using an optimised point-acquisition protocol. Preliminary results suggest that this method, alongside the standard RMS and residual point error distribution, may be used to provide the surgeon with a reliable indication of registration outcome in the operating room.

Background

Obtaining accurate alignment in total knee arthroplasty (TKA) remains a concern. Patient specific instrumentation (PSI) created using preoperative 3D modelling was developed to offer surgeons a simplified, reliable, efficient and customised TKA procedure.

Purpose

Surgical training is based on an apprenticeship model. This training can be divided broadly into three main categories: practical skills, knowledge and decision making. The operating room is the nexus of a large part of surgical teaching. The supervising surgeon imparts both practical teaching as well as didactic information to the trainee during surgical procedures. A large amount of decision making skills are also acquired in the OR. Indeed, a large part of the surgical teams time is spent in the operating room which makes it an ideal educational environment.

Bench model training is one teaching modality whereby the novice surgeon is taught surgical skills on life-like models. This practice enhances and accelerates the ability of the trainee to acquire fundamental, technical and surgical skills in the operating room. Whether bench model training provides an advantage on the ability of the trainee to acquire knowledge and decision making skills is unknown. Based on the motor learning theories, it is hypothesized that bench-model training will allow junior residents to be more interactive than trainees lacking similar active hands-on training. In this study, we examined whether bench model training provides an advantage on the ability of the trainee to acquire knowledge and decision making skills.

Aim

The aim of this study was to validate the information on operating room ventilation reported to the Norwegian Arthroplasty Register (NAR) and to assess the influence of this ventilation on the risk of revision due to infection after primary total hip arthroplasty (THA).

The aim of this study was to validate the information on operating room ventilation reported to the Norwegian Arthroplasty Register (NAR). We then wanted to assess the influence of operating room ventilation on the rate of revision due to infection after primary THA performed in operating rooms with conventional ventilation, “greenhouse”–ventilation and Laminar Airflow ventilation (LAF).

We identified cases of THA revisions due to deep infection and the type of ventilation system reported to the NAR from the primary THA. We included 5 orthopaedic units reporting 17947 primary THAs and 136 (0.8%) revisions due to infection during the 28 year inclusion period from 1987 to 2014. The hospitals were visited and the current and previous ventilation systems were evaluated together with the hospitals head engineer, and the factual ventilation on the specific operating rooms was thereby assessed. The association between revision due to infection and operating room ventilation was estimated by calculating relative risks (RR) in a Cox regression model.

73% of the primary THAs were performed in a room with LAF, in contrast to the reported 80 % of LAF. There was similar risk of revision due to infection after THA performed in operating rooms with laminar air flow compared to conventional ventilation (RR=0.7, 95 % CI: 0.2–2.3) and after THA performed in operating rooms with “greenhouse”-ventilation compared to conventional ventilation (RR=1.2, 0.1–11).

Surgeons are not fully aware of what kind of ventilation there is in the operating room. This study may indicate that, concerning reduction in incidence of THA infection, LAF does not justify the substantial installation cost. The numbers in the present study are too small to conclude strongly. Therefore, the study will be expanded to include all hospitals reporting to the NAR.

Introduction: Wound Hemearthrosis remains a major concern following TKA. This prospective study evaluates the use of a knotless interlocking suture system and its relationship to wound appearance and OR efficiency.

Methods: Two groups of patients undergoing TKA in our institution were evaluated using two different wound closure techniques. Group I consisted of twenty five patients who underwent standard closure using interrupted vicryl for the arthrotomy, deep fascia, superficial fascia, followed by staples. Group II consisted of twenty five patients who underwent closure using three separate running barbed sutures (Quill, Angiotech Inc)– first for the arthrotomy, followed by deep fascia, subcuticular and staples. We compared closure times, drain output and postoperative day to achieve zero wound drainage on the dressings.

Results: Closure times for Group II averaged 10 minutes faster than Group I. Drain output was decreased in the barbed suture cohort. Wounds achieved zero drainage, on average, one day sooner in Group II and no patients were returned to the OR for hematoma evacuation or arthrotomy disruption.

Conclusions: Use of this new technique for closure of TKA incisions can lead to faster operative times, lower drainage outputs and less immediate postoperative wound drainage. It appears that hemostasis is obtained quicker with the use of this barbed suture system while at the same time while maximizing OR efficiency.

Aim

The aim of this study was to assess the influence of the true operating room (OR) ventilation on the risk of revision due to infection after primary total hip arthroplasty (THA) reported to the Norwegian Arthroplasty Register (NAR).

INTRODUCTION

Adult reconstructive orthopedic surgery in the United States is facing an imminent logjam due to the increasing divergence of the demand for services and the ability for the community to supply those services. In combination with several other factors, a perfect storm is brewing that may leave the system overtaxed and the patient population suffering from either a lack of treatment, or treatment by less qualified providers. A key component to improving the overall efficiency of surgical care is to introduce enabling technologies that can effectively increase the throughput while simultaneously improving the quality of care. One such enabling technology that has proven itself in many industries is robotics, which has recently been introduced in surgery with even more recent applications in orthopedic surgery. A surgeon interactive robotic arm has been developed for partial knee arthroplasty (PKA) and total hip arthroplasty (THA). This study aims to analyse the efficiency of a new robotic technology for use in orthopaedic surgery.

Summary: Intraoperative assessment of knee kinematics during passive flexion and extension of the unloaded knee fails to adequately replicate the kinematics of the loaded knee during a functional activity.

Introduction: Intraoperatively, the alignment and stability of the prosthetic knee are assessed by observing the motion of the articular surfaces during passive flexion/extension. However, this examination is performed via a medial arthrotomy with limited visibility of the articular surfaces and with the joint unloaded. In view of these limitations of the intraoperative exam, this study was conducted to determine whether unloaded knee motion observed on the operating table is predictive of the motion of the knee during a loaded functional activity.

Methods: Six cadaveric knees were tested:

in a simulator which reproduced the manual intraoperative manipulation of the knee during unloaded passive range of motion (PROM), and

Standard 14cm midvastus medial arthrotomies were performed on each knee, and the PROM and squatting simulations were repeated. A laser scanner was used in conjunction with CT models to recreate the three-dimensional position of the knee and allow calculation of medial and lateral femoral rollback and tibial rotation.

Results: With PROM, the femoral condyles translated posteriorly (medial: 6.8±2.2mm, lateral: 15.2±1.3mm) and the tibia rotated internally (13.8±2.0°). A similar motion pattern was observed during squatting with slightly less medial (5.2±0.7mm; p=0.57), and lateral (12.8±0.9mm; p=0.06) rollback and rotation (10.7±1.54°; p=0.30). Interestingly, paradoxical anterior translation of the femur (> 2mm) and external rotation of the tibia (> 2°) were observed in 30% of knees during a loaded squat; however, this motion was not predicted by the PROM test.

Discussion: Similar knee kinematics are observed during unloaded flexion/extension and a physiologic squatting activity. However, the unloaded intraoperative test was unable to predict the occurrence of paradoxical motion during functional loading. Therefore, passive intraoperative testing of the knee is of limited value as a predictor of functional knee biomechanics.

Nowadays, foot switches are used in almost every operating theatre to support the interaction with medical devices. Foot switches are especially used to release risk-sensitive functions of e.g. the drilling device, the high-frequency device or the X-ray C-arm. In general, the use of foot switches facilitates the work, since they enable the surgeon to use both hands exclusively for the manipulation within the operation procedures. Due to the increasing number of (complex) devices controlled by foot switches, the surgeons face a variety of challenges regarding usability and safety of these human-machine-interfaces.

In the future, the approach of integrated medical devices in the OR on the basis of the open communication standard IEEE 11073 gives the opportunity to provide a central surgical cockpit with a universal foot switch for the surgeon, enabling the interaction with various devices different manufacturers. In the framework of the ongoing OR.NET initiative founded on the basis of the OR.NET research project (2012–2016) a novel concept for a universal foot switch (within the framework of a surgical workstation) has been developed in order to optimise the intraoperative workflow for the OR-personnel.

Here, we developed three wireless functional models of a universal foot switch together with a standardised modular interface for visual feedback via a central surgical cockpit display. Within the development of our latest foot switch, the requirements have been inter alia to provide adequate functionalities to cover the needs for the interventions in the medical disciplines orthopaedic surgery, neurosurgery and ENT.

The evaluation has been conducted within an interaction-centered usability analysis with surgeons from orthopaedics, neurosurgery and ENT. By using the Thinking Aloud technique in a Wizard-of-Oz experiment the usability criteria effectiveness, learnability and user satisfaction have been analysed.

Regarding learnability 83.25% of the subjects stated that the usage of the universal foot switch is easy to learn. An average of 77,2% of users rated the usability of the universal foot switch between good and excellent on the SUS scale. The intuitiveness of the graphical user interface has been approved with 91.75% and the controllability with 83.25%. Finally, 86% of the subjects stated a high user satisfaction.

Thromboembolism following total hip arthroplasty is a common complication that may result in significant morbidity and mortality. Despite this, optimal prophylactic regimen is controversial. According to the literature, the prevalence of deep venous thrombosis during the early post-operative period ranges from 13% in patients utilizing low molecular weight heparin to 18% in patients treated with sequential compression devices alone.

We investigated the efficacy of a comprehensive approach encompassing the use of aspirin, intermittent compression devices (‘foot pumps’), and early mobilization in a cohort of 290 consecutive patients after non-cemented total hip replacements. The surgical procedures were carried out under epidural anesthesia in most cases (91%). All patients were allowed full weight bearing and received ambulation training starting on the first post-operative day. Ankle-high pneumatic boots (‘foot pumps’) were used early immediately surgery. Aspirin (325 mg po/qd) was used as a pharmacological measure to prevent thromboembolism. The presence of deep vein thrombosis was determined with the routine use of venous duplex scans on post-operative day number 5 to 10 (mean 6.8). The duration of the follow-up was 3 months. No patients were lost to follow-up.

Four distal DVT and two proximal DVT were detected in five patients (3%). None of the patients developed symptomatic pulmonary embolism during the follow-up period. There were no major wound complications.

Venous thromboembolic disease after hip replacement surgery is largely associated with postoperative immobilization and venous stasis. It is the authors’ opinion that a prevention strategy should include mechanical as well as pharmacological measures. The concomitant use of epidural anesthesia, “foot pumps”, aspirin and early full weight bearing ambulation may be effective in further reducing the incidence of DVT after surgery.

Purpose: The purpose of this study was two-fold. First, we wanted to compare the cost of liquid waste disposal from the operating rooms (ORs) via a 3rd party medical waste company, with utilization of the sewer system at Kingston General Hospital. Secondly, we sought to assess national trends in liquid waste disposal, in order to make a national recommendation for liquid waste disposal from the OR.

Method: The hospital cost for OR liquid waste disposal at Kingston General Hospital was calculated by weighing the liquid waste from 871 surgical cases over a 5-week period in 2008. The materials, manpower and weight of the waste were used to calculate the costs for the two methods of liquid waste disposal. Seventy teaching hospitals across Canada were surveyed to determine their practice of liquid waste disposal in the OR.

Results: The raw cost per kg of liquid waste disposal using a medical waste company was found to be 57.126 % greater than utilizing the sewer system. Using the sewer system resulted in a total cost reduction of 40% compared with using a medical waste company. Sixty-three out of seventy teaching hospitals across the nation (90%) were found to utilize medical waste companies, while seven out of seventy hospitals (10%) utilized the sewer system to dispose of liquid waste.

Conclusion: The sewer system is an under-utilized yet safe, legal, and cost effective way to dispose of liquid waste from the OR. Using the sewer system to dispose of liquid waste would save the Canadian health care system millions of dollars compared with disposal via medical waste companies.

The purpose of this study was to determine whether a laminar flow operating system reduces deep infection rates in Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA) and to examine the costs involved in implementing laminar flow technology. A retrospective analysis of deep infection rates in 759 patients who underwent THA and TKA was performed in one hospital prior to and after the introduction of a vertical laminar flow operating system together with the use of isolation body exhaust suits. A cost analysis was also performed on the cost of implementing laminar flow technology and the average inpatient hospital cost of managing a deep infection. A control group consisted of 387 THA and TKA performed in 2 years in a conventional operating theatre and follow up carried out to a mean of 29 months. There were 12 recorded deep infections, 3.1%. Case group consisted of 372 THA and TKA performed in 2 years after the introduction of a vertical laminar flow operating theatre together with the use of isolation body exhaust suits, with a mean follow up to 22 months. There were 4 recorded deep infections, 1.1%.

A comparison of deep infection rates yielded p value 0.06. There was a strong trend toward a reduction in deep infection rate in THA and TKA performed in the laminar flow theatre with the use of isolation body exhaust suits. The economic impact of deep infection in THA and TKA is vast and the cost of implementing laminar flow technology must be weighed against the deep infection rate as well as the number of operations performed at an institution.