Running head: COMPUTER-ASSISTED PREOPERATIVE PLANNING 1

Computer-Assisted Virtual Preoperative Planning and Postoperative Complications in

Intertrochanteric Hip Fracture Surgeries

Mitchell Ward

University of San Diego

HCIN 549 Biostatistics

Professor Alexandrea Cronin

August 21, 2020

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Computer-Assisted Virtual Preoperative Planning and Postoperative Complications in

Intertrochanteric Hip Fracture Surgeries

The aging population in the U.S. brings a rise in the risk for osteoporosis and it is

estimated that it will account for 3 million fractures and $25.3 billion in annual cost (Adeyemi &

Delhougne, 2019). The increasing risk of the U.S. population poses concerns as hip fractures are

associated with a 27% mortality rate (Adeyemi & Delhougne, 2019). Patient outcomes for

conventional surgeries are reported to have an unsatisfactory risk of mortality, functional

worsening, and diminished quality of life for intertrochanteric hip fractures (Jia, Zhang, Qiang,

Wu, & Chen, 2020).

An advanced preoperative method, computer-assisted virtual preoperative planning, has

been established however, and Jia et al. (2020) have published a study that evaluates the

procedures association with mortality rates and postoperative complications. Computer-assisted

virtual preoperative planning is based on 3-dimensional imaging that gives surgeons precise

details and simulations of procedures before the surgery is conducted (Jia et al., 2020).

Xiaoyang Jia is the primary author of the study and has many publications related to

orthopedics and fractures specifically. They are associated with the Department of Orthopedic

Surgery at Zhongshan Hospital in Shanghai, China. Additionally, they are affiliated with the

Department of Orthopedic Trauma at East Hospital, a part of Tongji University School of

Medicine.

How the research was conducted

The authors collected data from East Hospital, Tongji University School of Medicine and

claims to follow the Strengthening the Reporting of Observational Studies in Epidemiology

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(STROBE) reporting guideline for cohort studies (Jia et al., 2020). They used a database that

collected the electronic medical records from January 1, 2009 to March 31, 2018. Data included

patient population characteristics, injury details and surgical notes while the postoperative data

were from follow-up records. Inclusion criteria consisted of patients presenting intertrochanteric

hip fracture who were 65 years or older at the time of admission and had a proximal femoral nail

antirotation 2 (PFNA-II) as treatment. Exclusion eliminated patients that had multiple traumatic

injuries, bilateral hip fractures, pathological fractures, fractures that happened during inpatient

stays, previous fractures or surgeries on the current site, and patients who transferred to another

hospital after surgery or left the facility against medical advice (Jia et al., 2020).

Of the 1445 patients that were identified to have surgery for intertrochanteric hip

fractures, 224 were excluded due to meeting one or more of the exclusion criteria. The cohort

ended up consisting of 1221 patients and were separated into a virtual planning group or

conventional planning group. The virtual planning group underwent computer-assisted virtual

preoperative planning while the conventional group received conventional preoperative planning.

Each group was stratified by demographic criteria that is represented in Table 1 from the study

(Jia et al., 2020).

Table 1. Demographic characteristics of patients based on the type of preoperative planning

(taken from Association of Computer-Assisted Virtual Preoperative Planning With
Postoperative Mortality and Complications in Older Patients With Intertrochanteric Hip
COMPUTER-ASSISTED PREOPERATIVE PLANNING 4

Fracture).

The variable of which type of preoperative planning was conveyed to establish the

difference in intertrochanteric hip fracture surgery outcomes. Conventional planning group

patients had 2-dimensional or 3-dimensional imaging of the injured limb to map out the

procedure. In the virtual planning group, computed tomographic scans were entered into a

computer-assisted orthopedic research platform to create a 3-dimensional reconstruction of the

fracture location. Areas of importance were identified, and the procedures were simulated to
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obtain the required specifications of the procedure. Surgical procedures were conducted by their

own surgery team at East Hospital, Tongji University School of Medicine and were aligned with

the standard process and preoperative planning method (Jia et al., 2020).

Primary outcomes measured consisted of mortality rates and postoperative complications

recorded up to 90 days after surgery on outpatient records. Complications included myocardial

infarction, heart failure, stroke, kidney failure and sepsis. Secondary outcomes measured the

rates of outpatient visits, readmissions and reoperations within the same 90-day period.

Functional outcomes were also recorded at a year follow-up and consisted of three scoring

systems. The Harris hip score evaluated the function of patient hips on a 0-100 rating scale. A

Short Form 36 Health Survey Physical Component Summary (SF-36 PCS) was normalized and

used to obtain patient-documented health statuses on a 100-point scale. Finally, a visual analog

scale (VAS) was used to calculate the severity of pain on a scale ranging 0-10.

In addition to collecting the measurements above, a learning curve was also evaluated to

adjust for variances in procedures. The learning curve was utilized for patients who received

treatment from junior residents. Also, those that had data available for multiple deviations such

as reduction procedure duration and type, surgery time, number of fluoroscopic images and

amount of blood loss impacted the learning curve. A multivariable linear regression analysis

calculated the learning curve differences.

Collected Data, Analysis and Results

The virtual planning group resulted with lower 90-day mortality rates (9.1%; 95% CI,

6.4%-12.5% vs 13.5%; 95% CI, 10.2%-17.6%; HR, 0.64; 95% CI, 0.41-0.99; P = .04) than the

conventional group (Jia et al., 2020). Additionally, postoperative complications were less
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frequent in the virtual planning group as well (6.1%; 95% CI, 4.0%-9.1% vs 10.8%; 95% CI,

7.9%-14.5%; HR, 0.54; 95% CI, 0.32-0.90; P = .02).

Figure 1. Percentage of group and incident rate of mortality and postoperative complications
within 90-days after surgery

Analysis of complication-associated outpatient visits within 90-days after surgery was

found to be not significantly different between the virtual planning group (1.48 incidents) and the

conventional planning group (1.48 incidents; [IRR], 0.90; 95% CI, 0.49-1.68; P = .75). The rate

of hospital readmissions conveyed no significant difference as well between the groups. Virtual

planning group patients had a .99 incident rate and the conventional planning group had a rate of

1.01 (IRR, 0.91; 95% CI, 0.49-1.67; P = .76). Examining reoperations did reveal a significant

difference between the virtual planning group (.76 incidents) and the conventional planning

group (.97 incidents; IRR, 0.41; 95% CI, 0.22-0.76; P = .01).

Figure 3. Comparison of the number of incidents of reoperations, hospital readmissions and

complication-associated outpatient visits between virtual planning and conventional planning
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groups.

The learning curve for surgeries performed by junior surgical residents showed that

significant improvements in surgery duration occurred after 50 cases (mean [SD], 64.2 [3.5]

minutes for cases 1-50 vs 52.2 [4.8] minutes for cases 51-277; P < .001) in the virtual planning

group. While there weren’t significant changes in the conventional planning group until 100

cases (mean [SD], 63.1 [3.5] minutes for cases 1-100 vs 51.9 [4.9] minutes for cases 101-281; P

< .001). The quicker learning curve in the virtual planning group resulted in reaching the

minimum surgery duration, or platform stage, faster than the conventional planning group (Jia et

al., 2020). In the virtual planning group, 277 patients received treatment from junior surgical

residents compared to 281 patients in the conventional planning group. Figure 2 displays the

comparison of both groups by case number and its associated surgery duration time.

The duration of closed reduction procedures, number of fluoroscopic images, and the

estimated amount of blood loss all had a faster learning curve and reached their platform stages
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earlier in the virtual planning group than the conventional planning group (Jia et al., 2020). An

improvement in open reduction procedure conversion rates occurred after 26 cases in the virtual

planning group (5 of 25 procedures [20.0%] for cases 1-25 vs 14 of 252 procedures [5.6%] for

cases 26-277; P < .001) and not until after 75 cases in the conventional planning group (15 of 75

procedures [20.0%] for cases 1-75 vs 16 of 206 procedures [8.0%] for cases 76-281; P < .001).

Figure 2. Time of surgery learning curve using computer-assisted virtual preoperative planning
vs conventional preoperative planning (taken from Association of Computer-Assisted Virtual
Preoperative Planning With Postoperative Mortality and Complications in Older Patients With
Intertrochanteric Hip Fracture).

Conclusions

In order to successfully evaluate the association of computer-assisted virtual preoperative

planning with mortality and complication rates, propensity score matching was completed (Jia et

al., 2020). The method was an attempt to account for any covariates that may differ between the

conventional and virtual planning groups. Logistic regression analysis was used for the patient’s

mechanism of injury, prior functional status, sociodemographic attributes, which hip,

classification of fracture, the time of the surgery, medical history and assessment of the

American Society of Anesthesiologists (ASA) Physical Status Classification System (Jia et al.,

2020). There were 407 patient pairs once there was a balance between the two groups. It was
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determined that a standardized difference of less than 10% indicated a relatively small imbalance

between groups.

For mortality rates within 90-days of surgery, a cox proportional hazards regression

analysis was conducted. This type of regression was selected because the goal was to compare

groups with respect to a hazard; death. Postoperative complications within 90-days were

evaluated with a competing risk analysis to form cumulative incident function curves in order to

distinguish differences between the two groups with the Fine and Gray test (Jia et al., 2020).

Reoperations, hospital readmissions and complication-associated outpatient visits were evaluated

with Poisson regression analysis to model response variables. Multivariable linear regression

analyses were performed to asses the differences in functional outcomes and the changes in the

learning curve components to account for confounding factors (Jia et al., 2020). For all the test,

there was a significance threshold of p < .05 and they were paired and two sided.

Mortality and postoperative complication rates within 90-days of surgery in patients that

are 65 or older with intertrochanteric hip fractures were significantly lower when receiving

computer-assisted virtual preoperative planning when compared to conventional preoperative

methods. Complication-associated outpatient visist and readmissions proved to be not

significantly different in comparison to conventional preoperative methods. Although,

reoperations were significantly reduced for patients in the virtual planning group. Every aspect

under review for the learning curve including surgery duration, number of fluoroscopic images,

estimated blood loss and open and closed reduction procedures were improved faster in the

virtual planning group compared to the conventional planning group.

Strenghts and Weaknesses of the Selected Statistical Methods

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Reflecting on the tests used for statistical analysis, each method implemented was

relative to the data used. Cox proportional hazards regression is typically used as a survival

analysis method that considers several risk factors and relates them to survival time (Boston

University School of Public Health, 2016) therefore, the regression is suitable for assessing

mortality risk. The Fine and Gray test was used for postoperative complications because when

applied, it directly evaluates the effects of covariates on the specified cumulative incidence

function Li, Scheike, & Zhang, 2015). Reoperation, hospital readmission and complication-

associated outpatient visit data were collected to evaluate the effect of intertrochanteric hip

fracture preoperative methods on their occurrences. A Poisson regression conveys which

explanatory variables have a significant effect on the response variables listed and is used for

events that don’t often occur (Glen, 2016). The baseline characteristics of patients and aspects of

the learning curve are potential confounding factors for postoperative functional outcomes and

the changes in the learning curve respectively. Multiple linear regression fits this type of data to

asses the relationship between the explanatory variables and a response variable (Yale

University).

Although the statistical methods used were suitable and relevant to the data and inquiries,

there were some methods that I believe to be impacting results. The major concern I had was

with the use of surgeons at variables levels of experience and expertise. There were substantial

learning curve methods to adjust for junior surgical residents and other factors. However, if there

is a way to avoid the variance in surgeons, the method would not have been necessary in that

instance and there would be more uniformity throughout the study. There is potential for other

complications with reducing sample sizes and increasing exclusion criteria as it may deviate

from real world applications. Considering this study is relatively novel in the exploration of the
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computer-assisted virtual preoperative planning method, I believe that starting out with more

specific parameters and reducing as many covariates as possible is the best way to obtain a

fundamental understanding of its impact.

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References

Adeyemi, A., & Delhougne, G. (2019). Incidence and Economic Burden of Intertrochanteric

Fracture. JBJS Open Access, 4(1). doi:10.2106/jbjs.oa.18.00045

Boston University School of Public Health. (2016). Cox Proportional Hazards Regression

Analysis. Retrieved from https://sphweb.bumc.bu.edu/otlt/mph-

modules/bs/bs704_survival/BS704_Survival6.html

Glen, S. (2016, September). Poisson Regression / Regression of Counts: Definition. Retrieved

from https://www.statisticshowto.com/poisson-regression/

Jia, X., Zhang, K., Qiang, M., Wu, Y., & Chen, Y. (2020). Association of Computer-Assisted

Virtual Preoperative Planning With Postoperative Mortality and Complications in Older

Patients With Intertrochanteric Hip Fracture. JAMA Network Open, 3(8).

doi:10.1001/jamanetworkopen.2020.5830

Li, J., Scheike, T. H., & Zhang, M. J. (2015). Checking Fine and Gray subdistribution hazards

model with cumulative sums of residuals. Lifetime data analysis, 21(2), 197–217.

https://doi.org/10.1007/s10985-014-9313-9

Yale University. (n.d.). Multiple Linear Regression. Retrieved from

http://www.stat.yale.edu/Courses/1997-98/101/linmult.htm