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Association of overlapping surgery with increased risk for complications following hip surgery: a population-based, matched cohort study


Importance —Overlapping surgery, also known as double-booking, refers to a controversial practice in which a single attending surgeon supervises 2 or more operations, in different operating rooms, at the same time.

Objective — To determine if overlapping surgery is associated with greater risk for complications following surgical treatment for hip fracture and arthritis.

Design, Setting, and Participants — This was a retrospective population-based cohort study in Ontario, Canada (population, 13.6 million), for the years 2009 to 2014. There was 1 year of follow-up. This study encompassed 2 large cohorts. The “hip fracture” cohort captured all persons older than 60 years who underwent surgery for a hip fracture during the study period. The “total hip arthroplasty” (THA) cohort captured all primary elective THA recipients for arthritis during the study period. We matched overlapping and nonoverlapping hip fractures by patient age, patient sex, surgical procedure (for the hip fracture cohort), primary surgeon, and hospital.

Exposures — Procedures were identified as overlapping if they overlapped with another surgical procedure performed by the same primary attending surgeon by more than 30 minutes.

Main Outcomes and Measures —Complication (infection, revision, dislocation) within 1 year.

Results — There were 38 008 hip fractures, and of those, 960 (2.5%) were overlapping (mean age of patients, 66 years [interquartile range, 57-74 years]; 503 [52.4%] were female). There were 52 869 THAs and of those, 1560 (3.0%) overlapping (mean age, 84 years [interquartile range, 77-89 years]; 1293 [82.9%] were female). After matching, overlapping hip fracture procedures had a greater risk for a complication (hazard ratio [HR], 1.85; 95% CI, 1.27-2.71; P = .001), as did overlapping THA procedures (HR, 1.79; 95% CI, 1.02-3.14; P = .04). Among overlapping hip fracture operations, increasing duration of operative overlap was associated with increasing risk for complications (adjusted odds ratio, 1.07 per 10-minute increase in overlap; P = .009).

Conclusions and Relevance — Overlapping surgery was relatively rare but was associated with an increased risk for surgical complications. Furthermore, increasing duration of operative overlap was associated with an increasing risk for complications. These findings support the notion that overlapping provision of surgery should be part of the informed consent process.



Ravi B, Pincus D, Wasserstein D, Govindarajan A, Huang A, Austin PC, Jenkinson R, Henry PDG, Paterson JM, Kreder HJ. JAMA Intern Med. 2018; 178(1):75-83. Epub 2017 Dec 4.

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