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Association of Overlapping Surgery With Increased Risk for Complications Following Hip SurgeryA Population-Based, Matched Cohort Study

Educational Objective
To determine if overlapping surgery is associated with greater risk for complications following surgical treatment for hip fracture and arthritis.
1 Credit CME
Key Points

Question  What is the association of overlapping surgery with increased risks for complications following surgical treatment of hip fractures and end-stage arthritis?

Findings  In this population-based cohort study of patients with hip fracture and hip arthritis, there were 960 and 1560 overlapping procedures, respectively. For patients undergoing overlapping procedures, there was an approximately 90% increase in the risk for surgical complications at 1 year, although the association was weaker in elective hip replacements than in hip fractures.

Meaning  Overlapping surgery is associated with an increased risk for complications in hip surgery, particularly for nonelective procedures.


Importance  Overlapping surgery, also known as double-booking, refers to a controversial practice in which a single attending surgeon supervises 2 or more operations, in different operating rooms, at the same time.

Objective  To determine if overlapping surgery is associated with greater risk for complications following surgical treatment for hip fracture and arthritis.

Design, Setting, and Participants  This was a retrospective population-based cohort study in Ontario, Canada (population, 13.6 million), for the years 2009 to 2014. There was 1 year of follow-up. This study encompassed 2 large cohorts. The “hip fracture” cohort captured all persons older than 60 years who underwent surgery for a hip fracture during the study period. The “total hip arthroplasty” (THA) cohort captured all primary elective THA recipients for arthritis during the study period. We matched overlapping and nonoverlapping hip fractures by patient age, patient sex, surgical procedure (for the hip fracture cohort), primary surgeon, and hospital.

Exposures  Procedures were identified as overlapping if they overlapped with another surgical procedure performed by the same primary attending surgeon by more than 30 minutes.

Main Outcomes and Measures  Complication (infection, revision, dislocation) within 1 year.

Results  There were 38 008 hip fractures, and of those, 960 (2.5%) were overlapping (mean age of patients, 66 years [interquartile range, 57-74 years]; 503 [52.4%] were female). There were 52 869 THAs and of those, 1560 (3.0%) overlapping (mean age, 84 years [interquartile range, 77-89 years]; 1293 [82.9%] were female). After matching, overlapping hip fracture procedures had a greater risk for a complication (hazard ratio [HR], 1.85; 95% CI, 1.27-2.71; P = .001), as did overlapping THA procedures (HR, 1.79; 95% CI, 1.02-3.14; P = .04). Among overlapping hip fracture operations, increasing duration of operative overlap was associated with increasing risk for complications (adjusted odds ratio, 1.07 per 10-minute increase in overlap; P = .009).

Conclusions and Relevance  Overlapping surgery was relatively rare but was associated with an increased risk for surgical complications. Furthermore, increasing duration of operative overlap was associated with an increasing risk for complications. These findings support the notion that overlapping provision of surgery should be part of the informed consent process.

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Article Information

Corresponding Author: Bheeshma Ravi, MD, PhD, Department of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, 43 Wellesley St E, Room 315, Toronto, ON M4Y 1H1, Canada (heeshma.ravi@sunnybrook.ca).

Accepted for Publication: September 16, 2017.

Published Online: December 4, 2017. doi:10.1001/jamainternmed.2017.6835

Author Contributions: Dr Ravi had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Ravi, Pincus, Wasserstein, Jenkinson, Paterson, Kreder.

Acquisition, analysis, or interpretation of data: Ravi, Pincus, Govindarajan, Huang, Austin, Jenkinson, Henry, Paterson.

Drafting of the manuscript: Ravi, Pincus, Wasserstein, Huang.

Critical revision of the manuscript for important intellectual content: Ravi, Pincus, Wasserstein, Govindarajan, Austin, Jenkinson, Henry, Paterson, Kreder.

Statistical analysis: Ravi, Pincus, Wasserstein, Huang.

Administrative, technical, or material support: Ravi, Wasserstein, Jenkinson, Paterson.

Study supervision: Wasserstein, Jenkinson, Kreder.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by the Institute for Clinical Evaluative Sciences (ICES), an independent research institute funded by the Ontario Ministry of Health and Long-Term Care. Parts of this material are based on data and information compiled and provided by the Canadian Institute for Health Information (CIHI). This study was supported by internal funding from the Marvin Tile Chair in Orthopaedic Surgery at Sunnybrook Health Sciences Centre, Toronto, Canada.

Role of the Funder/Sponsor: The supporting organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

Disclaimer: The opinions, results, and conclusions reported in this study are those of the authors and are independent from the funding sources and CIHI. No endorsement by the Institute for Clinical Evaluative Sciences, the Ontario Ministry of Health and Long-Term Care and CIHI is intended or should be inferred.

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