Assessment of Short-Term Patient Outcomes Following Overlapping Orthopaedic Surgery at a Large Academic Medical Center

Abstract

Background: Overlapping surgery is a long-standing practice that has not been well studied. The aim of this study was to assess whether overlapping surgery is associated with untoward outcomes for orthopaedic patients. Methods: Coarsened exact matching was used to assess the impact of overlap on outcomes among elective orthopaedic surgical interventions (n = 18,316) over 2 years (2014 and 2015) at 1 health-care system. Overlap was categorized as any overlap, and subcategories of exclusively beginning overlap and exclusively end overlap. Study subjects were matched on the Charlson comorbidity index score, duration of surgery, surgical costs, body mass index, length of stay, payer, and race, among others. Serious unanticipated events were studied. Results: A total of 3,395 patients had any overlap and were matched (a match rate of 90.8% of 3,738). For beginning and end overlap, matched groups were created, with a match rate of 95.2% of 1043 and 94.7% of 863, respectively. Among matched patients, any overlap did not predict an unanticipated return to surgery at 30 days (8.2% for any overlap and 8.3% for no overlap; p = 0.922) or 90 days (14.1% and 14.1%, respectively; p = 1.000). Patients who had surgery with any overlap demonstrated no difference compared with controls with respect to reoperation, readmission, or emergency room (ER) visits at 30 or 90 days (a reoperation rate of 3.1% and 3.2%, respectively [p = 0.884] at 30 days and 4.2% and 3.5% [p = 0.173] at 90 days; a readmission rate of 10.3% and 11.0% [p = 0.352] at 30 days and 5.5% and 5.2% [p = 0.570] at 90 days; and an ER visit rate of 5.2% and 4.6% [p = 0.276] at 30 days and 4.8% and 4.3% [p = 0.304] at 90 days). Patients with surgical overlap showed reduced mortality compared with controls during follow-up (1.8% and 2.6%, respectively; p = 0.029). Patients with beginning and/or end overlap had a similar lack of association with serious unanticipated events; however, patients with end overlap showed an increased unexpected rate of return to the operating room after reoperation at 90 days (13.3% versus 9.7%; p = 0.015). Conclusions: Nonconcurrent overlapping surgery was not associated with adverse outcomes in a large, matched orthopaedic surgery population across 1 academic health system. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Increasing Nonconcurrent Overlapping Surgery Is Not Associated With Outcome Changes in Lumbar Fusion

“…3 Previous literature across multiple surgical services has not demonstrated an increase in morbidity, mortality, or complication rate, despite occasionally finding an increased duration of surgery. [4][5][6][7] There are similar results for overlap within neurosurgery, with previous studies reporting noninferior outcomes following all neurosurgical procedures, 8,9 elective neurosurgical procedures, 10 pituitary adenoma resection, 11 microvascular decompression, 12 and spine surgery. 13 Although these reports suggest that surgical overlap is safe, few studies have evaluated whether an increasing amount of overlap during surgery confers additional risk to patients.…”

Overlapping Surgery in Orthopaedics: A Review of Efficacy, Surgical Costs, Surgical Outcomes, and Patient Safety

“…Eleven articles met the inclusion criteria, encompassing a total of approximately 119,410 surgeries (Supplemental Table 2, http://links.lww.com/JAAOS/A958). [1][2][3]5,6,[9][10][11][12][13][14] Of these, 34,494 (29%) were overlapping and 84,916 (71%) were nonoverlapping (Supplemental Table 3, http://links. lww.com/JAAOS/A959).…”

“…Three studies consisted of procedures occurring at multiple hospitals, with one study covering procedures at 75 Ontario hospitals. 1,2,6 Variation also existed in the type of orthopaedic procedures occurring (Supplemental Table 2, http://links.lww.com/ JAAOS/A958). The most commonly reviewed surgeries were joint reconstructions, with six of the 11 studies focusing solely on overlapping surgeries in arthroplasty.…”

Concurrent and Overlapping Surgery: Perspectives from Surgeons on Spinal Posterior Instrumented Fusion for Adolescent Idiopathic Scoliosis

“…The difference of opinion held by surgeons regarding simultaneous surgery compared with their patients may be based on literature showing no clinically significant difference in outcomes between overlapping and non-overlapping surgery. In a study of 18 316 elective orthopaedic procedures (3395 overlapping), Glauser et al 3 found no difference in reoperation, readmission or emergency room visit rates at 30 or 90 days compared with matched controls. In a cohort of 4786 primary THA/TKA patients undergoing simultaneous surgeries of at least 30 minutes, Zachwieja et al 5 found no difference in readmission rate, length of stay or rates of discharge.…”

“…Recent studies have attempted to evaluate outcomes of, as well as patient perspectives regarding, simultaneous surgery. Glauser et al 3 found no short-term adverse outcomes after overlapping surgery at a large academic medical centre. On the other hand, Bryant et al 4 showed that parents of patients undergoing posterior instrumentation and fusion (PSIF) for adolescent idiopathic scoliosis (AIS) were not agreeable to simultaneous scheduling of any type, even when presented with research demonstrating the safety of simultaneous surgery.…”