Infection rate after total shoulder joint replacement is greater for cases with operative time over three hours - can a huddle help?

Recently, the authors of The Effect of Operative Time on Surgical Site Infection Following Total ShoulderArthroplasty sought to determine the correlation between operative time and 30 day surgical site infection (SSI) following total shoulder arthroplasty (TSA) using the American College of Surgeons National Surgical Quality Improvement Program  database

Of the 33,470 patients in this study, 169 patients (0.50%) developed an SSI in the 30-day postoperative period. Longer operative times were associated with higher rates of SSI. There was a significant increase in the rate of SSI occurrences for operative times over 180 minutes.

Comment:  Both operative time and infection rate are influenced by patient factors (age, diagnosis, severity of pathology, patient co-morbidities, sex, BMI, physical robustness, medications), surgical factors (type of anesthesia, implant type, and intraoperative complications), and the experience of the surgeon and surgical team.

The authors of The effect of surgeon and hospital volume on shoulder arthroplasty perioperative quality metrics found that surgeon case volume was inversely correlated with operative time for shoulder arthroplasty. High-volume surgeons performed shoulder arthroplasty 30 to 50 minutes faster than low-volume surgeons did.

Higher surgeon case volume may reflect the efficiencies of the surgical team, more astute patient selection, and more organized pre and post surgical care. A blog post on this research (see this link)  pointed out that longer surgical times mean more time at risk for contamination.

We have found that a pre-operative huddle including the surgical, anesthesia, nursing and vendor teams can substantially reduce operative time by reviewing the patient and shoulder characteristics and anticipating issues that may arise during the case (hypotension, bleeding, fracture, need for special implants, graft, intraoperative imaging, change in positioning). Allowing each person the chance to express possible concerns has proven invaluable. See The impact of a daily pre-operative surgical huddle on interruptions, delays, and surgeon satisfaction in an orthopedic operating room: a prospective study

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

Do faster shoulder arthroplasty surgeons get better results?

 Is There an Association Between Operative Time and Length-of-Stay after Shoulder Arthroplasty?

These authors reviewed data on 14,449 primary shoulder arthroplasty cases found in the National Surgical Quality Improvement Program (NSQIP) database  between 2008 and 2016.

Overall, the mean length of stay was 2 ± 2 days.  Multivariate analysis showed that after adjusting for patient factors (age, sex, BMI, and ASA, longer operative times were associated with with longer hospital stays. 

They pointed to the importance of operating room efficiency on healthcare quality and economics after shoulder arthroplasty. They state, "Hence, based on the results of this study, it seems that surgeons who wish to perform shoulder arthroplasty procedures should strive to become proficient, and dedicate time and effort into decreasing operative time during their TSA and RTSA".

Comment: There is no question that longer surgical times and longer hospital stays lead to increased costs of care. However, the implication of this study is that longer surgery times cause longer lengths of stay, whereas in fact it only showed that longer surgery was associated with longer lengths of stay. It seems likely that more complex cases had both longer operating times and longer hospital stays - unfortunately the study did not stratify cases by diagnosis; thus cases of arthroplasty for fracture were mixed with cases for primary arthritis. It remains to be seen whether, for example, shorter times for anatomic shoulder arthroplasty for osteoarthritis were indeed associated with shorter lengths of stay. This could be addressed simply by plotting OR time vs length of stay for each diagnosis and each procedure type (TSA and RTSA). 

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).