Wrong Site Surgery Highest Among Spine Surgeons
Joseph Bosco, III, M.D. is vice chair of the Department of Orthopedic Surgery at The New York University Langone Hospital for Joint Diseases. Dr. Bosco, who is also director for the Center for Quality and Patient Safety, walks the halls with prevention in mind.
Dr. Bosco and his colleagues recently published an article on wrong-site surgery in The Journal of Bone and Joint Surgery. He told OTW, “We can’t assume that the problem has disappeared because we have instituted the Sign Your Site program. Our most recent data show that 21% of hand surgeons, 50% of spine surgeons, and 8.3% of knee surgeons have performed wrong-site surgery on at least one occasion.”
What? Really? How?
“There is more and more pressure to increase surgical volume and operate more efficiently, ” says Dr. Bosco. “All you need is for the proverbial holes in the Swiss cheese to line up. If a physician schedules a left knee arthroscopy instead of a right knee arthroscopy, 99.99% of the time a nurse or other OR personnel will catch that. But the 0.01% does happen.”
“Problems can arise in spine cases, where there is often extensive deformity and abnormal pathology. You can get X-rays and show them to 10 spine surgeons; 5 will say the problem is at one level while the other 5 say it’s at another level.”
“On the joint replacement side, there was a case where the surgeon signed the patient’s right knee and the patient concurred that this was the correct knee. The physician assistant, however, prepped and draped the wrong knee; the surgeon thus operated on the wrong knee. The surgeon should have caught it…the nurses should have caught it. This is exactly why a preoperative time out is critical.”
Asked how he would proceed if he were to lead a commission to assess and rectify wrong-site surgery, Dr. Bosco stated, “We must ensure that the Universal Protocol is being utilized nationwide. Physicians and their teams must be thoroughly educated as to how to avoid such incidents; then we must verify that the protocol is being used. Videotaping procedures is an excellent way of determining compliance. Such checks are already done for police officers and airline pilots, so why not surgeons?”
“The entire team must stay in the moment, something that’s not so easy given the length of some procedures. But wrong-site surgery is everyone’s mistake. One person can make a mistake—but five cannot.”
Thomas A. Einhorn, M.D. is director of Clinical and Translational Research Development for the Department of Orthopaedic Surgery at The NYU Langone Hospital for Joint Diseases. “The numbers presented in this article are sobering. If this has not happened to you one might think, ‘How could someone make such a blunder?’ Frankly, it’s not so hard to see how it could happen. There was a hand surgeon in Boston who had a particularly full surgical caseload one day. He confused the incision on one of his carpal tunnel releases with that of a trigger finger case. The difference can be just a couple of centimeters; in a small patient it’s not a clear situation when you are not focused.”
“Efforts to correct this problem began with the Canadians, then the American Academy of Orthopaedic Surgeons instituted the Sign Your Site program. The Joint Commission has developed a Universal Protocol, but it is not used at every facility…and it is not being assessed for effectiveness. The publication of this recent JBJS Reviews article will hopefully drive the discussion and facilitate efforts to do more to address this problem.”
Bariatric Surgery Before TKR Is Cost-Effective
No surgeon wants to come up empty when it comes to offering care to patients. If a patient is morbidly obese, their risks for complications after elective joint replacement are higher than in normal weight patients, yes…but you still want to be able to provide solutions to fix their problems. A new study in The Journal of Bone and Joint Surgery suggests that bariatric surgery prior to total knee replacement (TKR) may be a cost-effective treatment strategy in morbidly obese patients with end-stage knee osteoarthritis. Alexander McLawhorn, M.D., M.B.A. is an Adult Reconstruction & Joint Replacement Fellow at Hospital for Special Surgery (HSS). He told OTW, “While we already knew that bariatric surgery is effective in treating morbid obesity, our team set out to determine whether or not it is cost effective to offer this option prior to elective knee replacement.”
“We used a computer model to synthesize the existing data on the costs and outcomes of bariatric surgery and TKR. We used the model to analyze two hypothetical groups of morbidly obese patients from the societal perspective. In the first group, patients received bariatric surgery two years prior to TKR. The second group received TKR immediately, without weight loss surgery. So, the former group suffered with knee arthritis for two additional years but some of this cohort enjoyed the delayed benefits from both weight loss and TKR, while the latter experienced an immediate bump in quality-of-life from TKR but not the benefits from surgical weight loss.”
“While we were hoping that the combination of bariatric surgery and TKR would be cost saving compared to TKR alone, we did not find this to be the case. Even in our sensitivity analyses there were few scenarios for which the combination was cost saving. However, the majority of scenarios were cost effective compared to TKR alone—meaning that the total accrued costs per patient for an accrued year lived in perfect health were below the amount society and healthcare payers, such as Medicare and private insurers, are willing to pay.”
“Surgeons should remember that this is a theoretical model that we used to aggregate the available evidence in order to form an educated opinion about whether bariatric surgery is a cost-effective option prior to TKR. You cannot totally rely on its results to make a definitive care decision for an individual patient. A patient’s preferences must be taken into account. Not every patient wants weight loss surgery, but our results should encourage joint replacement surgeons to start a conversation with their morbidly obese patients about consultation with a bariatric surgeon prior to TKR.”
“Going forward we are studying several large populations of patients who had bariatric procedures prior to TJR [total joint replacement]—both hip and knee replacements. We are taking a more in-depth look at the optimal timing of bariatric surgery in relation to TJR and outcomes such as in-hospital complications, 30- and 90-day complications, and risk of revision surgery. My hope is that this body of work opens the door to future prospective collaborations with our bariatric surgery colleagues.”
Matthew T. Provencher, M.D. Heading to Steadman Clinic
Matthew T. Provencher, M.D., chief of the Sports Medicine Service at Massachusetts General Hospital (MGH), won’t be at his post in a couple of months. Dr. Provencher, who assumed this position in 2013, will be heading to the Steadman Clinic in Vail, Colorado. He told OTW, “The last three years has been fantastic, and I am particularly proud of what my colleagues and I accomplished in the MGH Sports Medicine division. That said, being asked to join the Steadman Clinic was an opportunity that I could not pass up.”
“During my time at MGH I had several goals. One was to unite the many excellent clinical services at MGH that play a part in the care of the sports medicine patient. One of my strengths was to improve the collaboration across divisions and departments in the realm of sports medicine. For example, this has helped our outstanding concussion program work closer with sports medicine. We also established a high caliber sports physical therapy residency that has collegiate and pro team involvement. The program is now being expanded and may include specific fellowships (such as treating baseball players with shoulder injuries).”
“In addition, I also spearheaded the development of an athletic sleep program that takes the latest in evidence-based medicine and maximizes what we can do for athletes. I think we have succeeded in establishing a culture where sports medicine is really ‘Active Care for Life’…and is for everyone. We don’t just treat young athletic superstars; in fact, the majority of our patients are between their 40s and 60s.”
“It will also be difficult to say goodbye to the New England Patriots organization. I am humbled and honored to have worked with the wonderful people of the Kraft Group, the Kraft family, Bill Belichick, his staff, the medical staff, athletic trainers…and especially the players. It is an exceptionally well-led organization.”
“In April I will head to the Steadman Clinic, where I look forward to joining this highly accomplished group of surgeons, providers and administrators. My goal will be to carry the torch of excellence forward in the realms of clinical care, research, and education.”
