Overlapping surgery, though rare, linked with significant complication risk

The practice of overlapping surgery is relatively rare in hip surgeries in Ontario but is associated with a 90% increased risk, within a year, for complications such as infection and dislocation, reports a new study published today in JAMA Internal Medicine.

Overlapping surgery is a long-standing practice to improve the use of hospital resources, promote timely access to care, especially for emergent procedures such as hip fractures, and provide opportunities to educate surgical trainees. The primary surgeon supervises two or more operations in different rooms, at the same time, and is required to be present for critical parts of the procedure and readily available for other times, as needed.

In this first population-based study to examine the effects of overlapping surgery at the level of a health care system, the researchers looked at population-based cohorts of 38,008 hip fracture procedures between 2009 and 2014, and 52,869 hip replacement procedures performed between 2009 and 2015, across more than 75 hospitals in Ontario.

They found 2.5% or 960 hip fractures, and 3% or 1,560 hip replacements as overlapping surgery where procedures overlapped at 30 minutes or more, and where the primary surgeon was also performing another procedure. After matching overlapping with non-overlapping procedures, they report a 90% increase in risk for complications at one year. Specifically for hip fracture emergent procedures, they report with a surgical complication risk increase from 6.4% to 10.4%, with more overlap also associated with increasing risk for complications.

“It is important to note that the occurrence of overlapping surgery, for these procedures, was low. The other big takeaway from this study is that the possibility of overlapping provision of surgery should be part of the discussion between surgeon and patient when obtaining informed consent,” says Dr. Bheeshma Ravi, orthopaedic surgeon, Holland Musculoskeletal Program, Sunnybrook Health Sciences Centre, assistant professor, Department of Surgery, University of Toronto, and Institute of Clinical Evaluative Sciences fellow.

The researchers were able to examine complications that occurred at centres other than where the original procedure was performed, and long-term outcomes up to one year. Complications outcomes were infection, revision (need for repeat surgery in the same area), or dislocation. More than 70% of overlapping procedures were performed in teaching hospitals.

“These findings create an awareness of the potential risks of overlapping surgery and should encourage hospitals to consider ways to assure high quality surgical care in the face of a limited number of surgeons,” says Dr. Avery Nathens, Surgeon-in-Chief, at Sunnybrook Health Sciences Centre, which has a policy that speaks to restricting this practice.

This study is supported by Marvin Tile Chair in Orthopaedic Surgery at Sunnybrook Health Sciences Centre, and by the Institute for Clinical Evaluative Sciences.

For more information:
Natalie Chung-Sayers
Communications Advisor, Sunnybrook
(c): 416-710-3740 (o): 416-226-6780 ext. 57297