CORR Synthesis: What Is the Current Understanding of Overlapping Surgery in Orthopaedics, Particularly as it Relates to Patient Outcomes and Perceptions?

In the Beginning… Since the release of a seminal Boston Globe series on the topic in 2015 [1], the debate over overlapping and concurrent surgery has received attention both in the academic [25, 26, 31] and lay press [1, 33, 37]; it has also been fodder for high-profile litigation [28; 37]. The American College of Surgeons and United States Senate have issued guidelines for concurrent surgical practice [3, 43]. Overlapping surgery, the topic of this CORR Synthesis review, is defined as the co-occurrence of two distinct surgical procedures supervised by one attending surgeon in which the critical portions of the operations occur asynchronously [2]. The American College of Surgeons released a statement defining concurrent surgery as the time when the “critical or key components of the procedures for which the primary attending surgeon is responsible are occurring all or in part at the same time” [3], which the American Academy of Orthopaedic Surgeons adopted in 2016 [41]. Further subdivisions have been highlighted under the umbrella of “overlapping surgery,” including “staggered start cases,” “sequential start cases,” and “coinciding cases” [6, 22, 34, 35] . For this review, we will treat all of these under the broad rubric of “overlapping surgery” (Table 1). Table 1. - Definitions of common terminology Terminology Definition Synonyms Concurrent [3] Operations where the critical or key components of the procedures are occurring all or in part at the same time. Simultaneous [3] Overlapping [3] Procedures in which the critical and key elements of an operation have been completed and the surgeon is in another room performing the key and critical components of that operation. Running two rooms [35] Sequential [34] No portion of a subsequent procedure begins until all of the essential and nonessential components of the procedure before it are completely finished. Staggered [34] Operations that only overlap during the nonessential components of the procedures (induction, positioning, placing lines). Research across many surgical subspecialties has sought to evaluate the practice and safety of overlapping procedures [7, 9, 16, 18, 30, 36, 39, 45, 46]; herein, we focus on the evidence base in orthopaedic surgery. We contend that the policy and practice of overlapping surgery are important considerations not only for surgeons but also for hospital administration, leadership, and resident educators. Overlapping surgery typically is used to increase efficiency both for surgeons and anesthesiologists [31], but a possible benefit of overlapping surgery for patients may be decreased wait times for procedures [18]. For residency programs, overlapping surgery can also promote increased resident involvement, education, and autonomy [18]. This topic is especially important in orthopaedics as the specialty is second only to neurosurgery in terms of the frequency with which overlapping surgery is performed [40]. The Argument By keeping the key or critical portions of procedures from occurring at the same time, overlapping surgery has been deemed permissible, while concurrent surgery—defined as two or more procedures in which key or critical portions of two or more procedures occur simultaneously in different operating rooms—is considered inappropriate [2, 6, 22]. However, the determination of what is considered key and critical in any specific operation is left largely to each surgeon’s or institution’s discretion. The potential lack of clarity in the definitions may also result in a lack of standardization in practice among surgeons or in research methods, subsequently impeding the creation of a unifying consensus in organizations. Other important controversies include patient and family perceptions of the practice, potential influence on cost, impact on resident education, and the importance of consent practices that disclose to patients what, in fact, is about to happen to them. These controversies have only grown more prominent as members of the public have become increasingly aware of the issue, through coverage like the “Spotlight” series in the Boston Globe and other lay press reports [1, 28, 33]. Although some professional organizations have adopted guidelines [2, 4], and many individual surgical centers and institutions have developed their own policies, controversies and questions remain. Essential Elements We queried several search platforms (PubMed, Google Scholar, JAMA Online, and MEDLINE) to locate studies on overlapping and concurrent surgery. We searched for studies published between January 1, 2016 and September 30, 2019, using the keywords of “overlapping,” “concurrent,” “running/run two rooms,” “simultaneous,” “multiple rooms,” “surgeries,” “cases,” “operations,” “perceptions,” “outcomes,” “safety,” and “complications.” Studies were included if they were primarily concerned with overlapping or concurrent surgery in orthopaedics. Although several papers have been written on the topic of overlapping surgery in general surgery, plastic surgery, and otolaryngology, as well nonspecialty-specific analyses, this review focuses specifically on the study of orthopaedics and the procedures orthopaedic surgeons perform. We included all types of articles in this review, including outcomes-based research, surveys, commentary, and ethical analyses. We excluded studies that did not deal directly with overlapping surgery in orthopaedics or in orthopaedic-specific procedures (such as joint arthroplasty). Notably, we encountered several neurosurgical spine papers in the search query, but we excluded these to maintain the focus on orthopaedic studies. The search yielded 18 articles on overlapping and/or concurrent surgery in orthopaedics. Of these, nine constituted outcomes-based research comparing overlapping and nonoverlapping surgery [10, 14, 15, 20, 29, 32, 38, 42, 44]. Four articles administered surveys to patients, their families, and orthopaedic surgeons [6, 8, 11, 12]. The final five were ethical analyses or discussions [5, 21, 26, 27, 31]. For the nine outcomes-based studies, the quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria, which provide a framework to develop and present evidence [19]. Based on this assessment, six studies were of low-quality evidence [10, 14, 15, 29, 38, 42] and three studies were of very low–quality evidence [20, 32, 44] (Table 2). The quality of evidence for those three very low–quality evidence studies was downgraded for imprecision and risk of bias. Table 2. - Summary of overlapping surgery outcomes-based studies in orthopaedics Author Population Total sample size (OS sample size) Institution (single or multiple) and number of surgeons No differences Differences between OS and NOS Study design Quality of evidence (GRADE criteria) Troester et al. [42] Patients undergoing primary TKA 452 (177) Single, single surgeon Anesthesiology timeSix-week readmissions, return to operating room, medical or surgical complication rateRate of neutral coronal alignmentPresence of periprosthetic lucency RCS Low Murphy et al. [29] TKA 3633 (1851) Single, 26 surgeons Length of inpatient stay90-day mortality90-day emergency room visits90-day readmissionCMS payments Fewer skilled nursing daysMore home health visitsGreater procedure volumeIncreased procedures and operative time for surgeons on OS days RCS Low George et al. [14] Total joint arthroplasties 9192 (2669) Single Wound dehiscenceSuperficial infectionWound hematomaDuration of overlap and 90-day complications Longer operative timesFewer thromboembolic eventsFewer periprosthetic joint infections RCS Low Hamilton et al. [20] Primary hip and knee arthroplasties 16,916 (9914) Single, six surgeons Intraoperative complication rates90-day component revision rates90-day complication rates90-day reoperation rates RCS Very low Dy et al. [10] All inpatient orthopaedic surgical procedures performed at five academic institutions in one year 14,135 (5696) Multiple (five institutions), 215 surgeons Mortality More elective proceduresHigher proportion of total joint arthroplastiesLower chance of all-cause 30-day readmissionLower frequency of perioperative complicationsShorter length of stay RCS Low Goldfarb et al. [15] Patients who had undergone orthopaedic surgery at an ambulatory surgery center 22,220 (5198) Single, 21 surgeons Surgical site infectionNoninfectious surgical complicationsHospitalizationMorbidity Increased operative timeIncreased anesthesia timeIncreased total tourniquet time RCS Low Suarez et al. [38] Total joint arthroplasties 2833 (1610) Single, two surgeons 90-day rates of complicationsUnplanned readmissionsReoperations Increased operative time RCS Low Ravi et al. [32] Surgical treatment of hip fractures and end-stage arthritis 38,008 hip fractures (960)52,869 THAs (1560) Population-based, matched-cohort study using data from several health administrative databases from Ontario, Canada Increased hip fracture procedure complicationsGreater risk of complication in overlapping THA proceduresIncreased complications with increased duration of operative overlap RCS Very low Zhang et al. [44] All surgical procedures (including sports medicine, hand, and foot and ankle) performed at an ambulatory orthopaedic surgery center 3640 (2474) Single, four surgeons Mean procedure timeTotal operating room time30-day complicationsTotal versus subspecialty operations RCS Very low OS = overlapping surgery; NOS = nonoverlapping surgery; GRADE = Grading of Recommendations, Assessment, Development, and Evaluation; RCS = retrospective cohort study; CMS = Centers for Medicare and Medicaid Services. What We (Think) We Know Safety of Overlapping Orthopaedic Surgical Procedures Patient safety was the major topic of interest in overlapping surgery analyses and was assessed using endpoints like readmissions, mortality, morbidity, wound dehiscence, infection, hematoma, emergency department visits, reoperations, revisions, dislocations, and thrombotic events. A multicenter orthopaedic investigation of 14,135 procedures demonstrated no difference in 30-day readmissions, length of inpatient stay, and mortality between overlapping procedures and nonoverlapping procedures [10]. Another study echoed these findings but also demonstrated comparable conclusions in operating room times and total procedure times [44]. Unsurprisingly, operating time was increased in three studies, including the study with the largest database (22,220 operations), which reported increased operative, anesthesia, and tourniquet times in overlapping procedures compared with nonoverlapping procedures [14, 15, 38]. The largest database study found no difference in surgical site infection, postoperative hospitalizations, or morbidity, defined as the composite of surgical site infections, perioperative hospitalizations or unexpected same-day admissions, and noninfectious surgical complications [15]. Readmission and 90-day complication rates were not different between overlapping and nonoverlapping cohorts in four joint arthroplasty studies [14, 20, 29, 38]. Importantly, a large study about patients undergoing THA found that the increased duration of operative overlap was associated with increased risk of complications, including infection and early revision [32]. However, this paper acknowledged the rarity of overlapping procedures relative to nonoverlapping procedures in their database, suggesting that centers with more experience or volume may have lower rates of infection and early revision. In sum, the existing studies on overlapping orthopaedic surgical procedures seem to demonstrate noninferior outcomes, including infections, noninfectious complications, postoperative hospitalizations, and readmissions compared with nonoverlapping procedures, but overlapping procedures seemed to result in increased operative, anesthesia, and tourniquet times. Patient and Family Perceptions A small study of parents of adolescents undergoing spinal surgery used a Likert scale to ask parents to indicate their level of disagreement or agreement regarding various statements related to overlapping surgery. The study found that parents disagreed with any type of simultaneous surgery and with supervised trainees performing a critical portion of the operation [8]. Strikingly, in that study, comfort with overlapping surgery did not change when families were informed of research demonstrating its safety. When informed of the attending physician’s confidence in the resident, the parents’ agreement with directly supervised trainees performing critical portions of the operations improved, but their agreement with unsupervised trainees operating during noncritical portions did not [8]. Eighty-two percent of parents considered wound closure to be a critical portion of the operation, suggesting a vast gap between patients’ and surgeons’ perceptions of this step [6, 8]. A survey of 200 patients with trauma found that more than half had no prior knowledge of overlapping surgical practices, including 60% of patients who had already had surgery [12]. Assuming that these patients had undergone a surgical consent process, it is concerning that they were either not adequately informed or had forgotten the preoperative counseling. Patients were also asked to rate their concern regarding overlapping surgical practices on a scale of 1 to 5, with 1 representing “least concern” and 5 representing “most concern” [12]. Sixty-four percent of all patients expressed the least level of concern regarding the practice [12]. After reading the departmental position on overlapping procedures, 38% of patients had a lower level of concern than they did before, but 10% had a higher level of concern [12]. This suggests that sharing a department’s explicit policies might alleviate some patients’ concerns, but not all of them, a finding we believe deserves further attention. A similar cross-sectional study of a general patient and family population reiterated the public’s general ignorance of the practice and a strong desire for disclosure during the informed consent process [11]. The rationale behind patients’ concerns is also important to understand to provide effective patient education and counseling. In the survey of patients with trauma, the most frequently cited concerns were the lack of an attending physician in the operating room, risk of resident error, and risk of a missed procedural step [12]. The study of patients and family members found that increased hospital revenue was the most frequently perceived reason for the practice [11]. These surveys indicate that many patients and families are unaware of the practice of overlapping surgery. Particularly in the pediatric population, many families do not accept the practice, even during noncritical portions of the procedures. Although providing the departmental position on overlapping procedures may assuage some patients’ concerns, the overall lack of awareness of the practice of overlapping surgery warrants increased patient education and disclosure. Surgeon Perceptions One study examined surgeon perceptions of an operation’s “key or critical” components [6]. The authors divided the well-known and structured operations of TKAs and THAs into 12 steps. The results were unexpectedly disparate, with an overall mean agreement proportion of less than 10% for the definitions of key portions of these operations. However, more than 90% of the surgeons considered five of the 12 steps to be critical. Twenty-eight percent of surgeons deemed closure to be a critical portion of the procedure. These data indicate that there are important individual differences among surgeons’ perceptions of the critical portions of operations. Given that the definitions of overlapping surgery rest on the interpretation of “key or critical” components, there will almost certainly be disparities among surgeons’ and institutions’ interpretations of these definitions. However, it is somewhat encouraging that most surgeons overwhelmingly agreed on a core set of steps in these operations. The difference between patients’ and surgeons’ perceptions of “key or critical” components, such as the wide disparity in views of wound closure, seems especially important, and all of these discrepancies should cause surgeons to invest in thoughtful patient-education processes to narrow the gap between patients’ and physicians’ understandings. Ethics and Logistics Six publications presented ethical discussions on overlapping orthopaedic surgery, with an overwhelming consensus on the necessity of standardized, consistent, and explicit informed consent regarding the nuances of overlapping surgery [5, 21, 26, 27, 31, 42]. Emphasizing the current lack of agreement on what constitutes “key or critical” portions of specific orthopaedic procedures, some publications encouraged academic societies, organizations, and centers to provide specific definitions and guidelines [5, 6, 21, 26]. To our knowledge, no guidelines currently exist for specific procedures. The potential impact on resident training was discussed in two publications [26, 31]. These articles emphasize that residents must learn skills and surgical judgment by doing, but with appropriate supervision [26, 31]. For surgeons involved in resident education, there is a “responsibility to the next generation to teach the residents how to perform that surgery,” in addition to the obvious importance of being present for the “key part” to ensure patient safety [31]. Combined with the previously discussed importance of informed consent for patient autonomy, trainee involvement also requires thoughtful consideration of the principles of nonmaleficence and benevolence to support patient safety and well-being [26]. Knowledge Gaps and Unsupported Practices As in how studies overlapping surgery. For some studies overlapping as overlap overlap [20, 29, 32, any time that there were two simultaneously [10, 15, or specific Although than 10% of orthopaedic surgeons completely on what constitutes the key or critical portions of a specific more than 90% on the critical of several steps [6]. This finding the necessity of definitions and the of consensus guidelines from a individual definitions are and Although there are discrepancies in orthopaedic surgeons’ an even gap between how patients or families the and how surgeons understand The lack of patient awareness and of this practice many patients’ and of the practice and some patients’ of and the of more In addition to the to provide informed consent and among patients, and their families, the lack of definitions of overlapping surgery may also impact research and result in Importantly, other such as neurosurgery have the impact of overlapping surgery policies on finding no difference in hospital between overlapping and nonoverlapping procedures Of the included orthopaedic studies, only one on Centers for Medicare and Medicaid finding no difference in payments A further investigation of the and impact of overlapping surgery be to further the of this practice for patients, and Although not specifically in orthopaedic surgery, a neurosurgical study the impact of overlapping surgery policies on trainees [18]. This study found that procedures with a as the surgeon from to resident while also surgical wait time for patients [18]. As residency the influence of overlapping surgery policies on education, further research is in orthopaedics to the of these Notably, articles on the also the to maintain with patients on overlapping surgery while a strong to autonomy and critical supervision of residents and to The lack of definitions and terminology the interpretation of existing studies and impact research and at an academic consensus on the definitions also the to provide informed consent to of and for overlapping procedures existing studies. As various overlapping surgery policies in orthopaedics and their subsequent impact on should also be and in further the practice of overlapping surgery must also trainee involvement, informed and of what and patients’ and lack of knowledge and regarding overlapping surgery. studies seem to that even when on the only some patients and their families become more of the practice of overlapping surgery 12]. studies may be for the or where patients may be more or less to the several articles for such as the and of attending surgeon involvement in the procedure 26]. This not only in the medical but also quality and research studies. As discussed current evidence on overlapping orthopaedic surgery suggests noninferior compared with nonoverlapping surgery (including of infections, noninfectious complications, postoperative hospitalizations, and with the that all studies are small [10, 15, 29, 44]. Overlapping surgery practices may have the potential to and support trainee and if used [26, 31]. In the or further of overlapping surgery practices may in the training and of A of the studies is that most were in single institutions and/or about specific procedures, the of the We that increased standardization and consensus of definitions and terminology multicenter studies and the of research As current evidence suggests noninferior outcomes, most not existing studies are small to differences in but as all outcomes-based studies had or very low–quality as by the GRADE [19]. This is largely of the lack of on this which is in this but several publications were also most for or imprecision of other types that might In studies should the complications or to imprecision in data studies are by between key study methods, and We that increased public knowledge of overlapping surgery will and should increased patient education with and standardization of informed consent Given the disparities in definitions of overlapping surgery and “key or critical” portions of procedures, we believe that orthopaedic may to consensus guidelines on this we believe this will for and research practices for overlapping surgery and further of study, our knowledge of the We also that the impact of overlapping surgery on surgical education will be further as orthopaedic the influence of overlapping procedures on trainee and there is a of studies on the of and policies on orthopaedic surgery resident education [26, any policies result in to trainee education, with to no on

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