Study supports safety of overlapping surgery for outpatient orthopaedic procedures

At least for brief periods, overlapping surgery is safe for patients undergoing outpatient or "same-day" orthopaedic surgery procedures, reports a study in the December 19, 2018 issue of The Journal of Bone & Joint Surgery.

The study adds to a growing body of evidence showing no increase in the risk of complications for patients undergoing overlapping orthopaedic surgery—procedures where a single surgeon is the primary surgeon for more than one patient simultaneously in separate operating rooms. "Our data suggest that briefly overlapping surgery is a safe practice in the ambulatory orthopaedic surgery center," comments lead author Charles A. Goldfarb, MD, of Washington University School of Medicine, St. Louis.

New Data on Safety of Overlapping Ambulatory Orthopaedic Surgery

Dr. Goldfarb and colleagues compared the outcomes of overlapping versus nonoverlapping surgery at their university-affiliated orthopaedic ambulatory surgical center (ASC). In overlapping surgery, the attending surgeon is present for "critical" parts of the procedure, leaving another surgeon to perform noncritical portions—typically skin closure. Overlapping surgery is commonly used to maximize operating room efficiency.

Although this practice is not new, it has become controversial in the wake of recent high-profile media reports. Most previous studies of overlapping surgery have focused on inpatient procedures, performed on hospitalized patients.

The analysis included more than 22,000 outpatient orthopaedic procedures performed between 2009 and 2015. The patients underwent a wide range of elective surgeries, including knee, hand, and shoulder procedures. No joint replacement or spine operations were included in the analysis.

Twenty-three percent of the procedures were overlapping surgeries. Median overlap time in these procedures was eight minutes. According to this ASC's policy, another attending surgeon -not a resident or fellow in training—was present during the overlapping portion of the procedure.

The overall complication rate (morbidity) was 0.66 percent in the overlapping surgery group and 0.54 percent in the nonoverlapping surgery group. After the authors adjusted for other factors, the morbidity risk was not significantly different between groups. The same was true for all individual complications considered: surgical site infections, noninfection surgical complications, and transfer to an inpatient hospital.

Anesthesia and overall surgery times were slightly longer in the overlapping surgery group, but these surgical factors did not increase the risk of complications.

Most studies of orthopaedic and other types of overlapping surgery have reported no difference in complications, compared to non-overlapping surgery. A recent study in Journal of Bone and Joint Surgery found no increase in complication rate among inpatients undergoing overlapping orthopaedic surgery, compared to nonoverlapping cases.

The researchers note that although this study includes a large number of outpatient orthopaedic surgery cases, the data represent the experience of only one ASC. Nevertheless, the results suggest that overlapping orthopaedic surgery can be safely carried out in ambulatory surgery settings—at least as practiced at the authors' institution.

Dr. Goldfarb and colleagues conclude, "Practitioners, payers, and patients should be reassured that limited overlapping surgery is appropriate and reasonable in this setting."