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Scientific Articles   |    
Is After-Hours Orthopaedic Surgery Associated with Adverse Outcomes?A Prospective Comparative Study
William M. Ricci, MD1; Bethany Gallagher, MD1; Angel Brandt, MA1; John Schwappach, MD2; Michael Tucker, MD3; Ross Leighton, MD4
1 Washington University School of Medicine at Barnes-Jewish Hospital, One Barnes-Jewish Hospital Plaza, Suite 11300, St. Louis, MO 63110. E-mail address for W.M. Ricci: ricciw@wustl.edu
2 Colorado Orthopaedic Consultants PC, 1411 South Potomac Street, Suite 400, Denver, CO 80012
3 Palmetto Health Richland, 3 Richland Medical Park Drive, Suite 330, Columbia, SC 29203
4 Halifax Infirmary, Room 4875, Halifax, NS B3H 3A7, Canada
View Disclosures and Other Information
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from Smith and Nephew. In addition, one or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Smith and Nephew). Also, a commercial entity (Smith and Nephew) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors, or a member of his or her immediate family, is affiliated or associated.
A video supplement to this article will be available from the Video Journal of Orthopaedics. A video clip will be available at the JBJS web site, www.jbjs.org. The Video Journal of Orthopaedics can be contacted at (805) 962-3410, web site: www.vjortho.com.
Investigation performed at Washington University School of Medicine, St. Louis, Missouri; Swedish Medical Center, Englewood, Colorado; Medical College of Georgia, Augusta, Georgia; and Halifax Infirmary, Halifax, Nova Scotia, Canada

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2009 Sep 01;91(9):2067-2072. doi: 10.2106/JBJS.H.00661
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Abstract

Background: Treatment of fractures is sometimes performed after normal daytime operating hours and in such instances may be performed under less than ideal conditions. The consequence of performing operations under such conditions is largely unknown and was therefore studied in the context of intramedullary nail fixation of tibial and femoral shaft fractures.

Methods: Two hundred and three consecutive patients with either a femoral or tibial shaft fracture (Orthopaedic Trauma Association classification 32 or 42) treated with intramedullary nail fixation were included in a prospective, multicenter, nonrandomized study. Patients were divided into an after-hours group defined as an operation beginning from 4:00 P.M. to 6:00 A.M. or a daytime group defined as an operation beginning from 6:00 A.M. to 4:00 P.M. These groups were further divided on the basis of the injured bone into the following subgroups: after-hours femoral fracture (fifty-five patients), daytime femoral fracture (forty-four patients), after-hours tibial fracture (forty-eight patients), and daytime tibial fracture (fifty-six patients). The demographic and fracture characteristics were similar among the subgroups. All patients were treated with the same type of femoral antegrade, femoral retrograde, or tibial nail fixation with reaming. Data for fracture-healing, complications, operative time, and fluoroscopy time were collected prospectively.

Results: The healing rates were similar between daytime and after-hours surgery groups for both the tibial and femoral nailing. On the basis of univariate analysis, operative times were shorter in the after-hours group compared with the daytime group for both the tibial and femoral nail fixation groups (p < 0.02), but regression analysis failed to identify time of surgery as an independent variable associated with operative time. Radiation exposure was similar for the after-hours group and the daytime group for both tibial and femoral nail fixation (p > 0.05). The after-hours group had more unplanned reoperations than the daytime group (p < 0.02). Removal of painful hardware was more frequent in the after-hours femoral fracture group (27%) than in the daytime femoral fracture group (3%) (p < 0.02), and after-hours surgery was an independent variable associated with the need for removal of painful femoral fracture hardware (p < 0.05).

Conclusions: Rates of nonunion, infectious complications, and radiation exposure are similar for after-hours and daytime surgery for intramedullary nail fixation of both femoral and tibial fractures. After-hours femoral nail fixation was associated with an increased frequency for removal of painful hardware, which may be related to technical errors associated with nonideal conditions and shorter operative times. An increase in the allocated amount of daytime operative time for orthopaedic trauma surgery has the potential to reduce minor complication rates for intramedullary nail fixation.

Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    James G. Wright, MD, MPH, FRCSC
    Posted on October 05, 2009
    Dr. Wright responds to Drs. Bernstein and Ahn
    The Journal of Bone & Joint Surgery

    Dr. Bernstein is correct that, due to an editorial error, this paper should have been rated as a Prognostic rather than a Therapeutic study. As a prospective cohort study, consistent with JBJS Levels of Evidence criteria, this study was designated as Level I.

    Joseph Bernstein, MD
    Posted on September 19, 2009
    Not a Level I Therapeutic Study
    University of Pennsylvania, Philadelphia, Pennsylvania

    To the Editor:

    The article by Ricci et al. (1) was incorrectly designated as a Level I (therapeutic) study. According to the JBJS guidelines, a Level I therapeutic study is a randomized controlled trial, and this study was not that.

    The study perhaps could be considered under Prognostic Studies-Investigating the Effect of a Patient Characteristic on the Outcome of Disease (in this case, the "Patient Characteristic" is the time of the operation). In the JBJS guidelines, a Prognostic Study can be considered Level I if it were, "High-quality". Of course, the height of quality is a subjective judgment, but we question whether this study is of sufficiently high quality to be deemed Level I.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    Reference

    1. Ricci WM, Gallagher B, Brandt A, Schwappach J, Tucker M, Leighton R. Is after-hours orthopaedic surgery associated with adverse outcomes? A prospective comparative study. J Bone Joint Surg Am. 2009;91:2067-72.

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