Involvement of Residents Does Not Increase Postoperative Complications After Open Reduction Internal Fixation of Ankle Fractures: An Analysis of 3251 Cases

Ankle fracture surgery performed by orthopaedic residents without supervision has comparable outcomes to surgery performed by fellowship trained orthopaedic surgeons

BACKGROUND

Unstable fractures often necessitate open reduction and internal fixation (ORIF), which generally yield favourable outcomes. However, the impact of surgical trainee autonomy on healthcare quality in these procedures remains uncertain. We hypothesized that surgery performed solely by residents, without supervision or participation of an attending surgeon, can provide similar outcomes to surgery performed by trauma or foot and ankle fellowship-trained orthopaedic surgeons.

METHODS

A single-center cohort of an academic level-1 trauma center was retrospectively reviewed for all ankle ORIF between 2015 and 2019. Data were compared between surgery performed solely by post-graduate-year 4 to 6 residents, and surgery performed by trauma or foot and ankle fellowship-trained surgeons. Demographics, surgical parameters, preoperative and postoperative radiographs, and primary (mortality, complications, and revision surgery) and secondary outcome variables were collected and analyzed. Univariate analysis was performed to evaluate outcomes.

RESULTS

A total of 460 ankle fractures were included in the study. Nonoperative cases and cases operated by senior orthopaedic surgeons who are not trauma or foot and ankle fellowship-trained orthopaedic surgeons were excluded. The average follow-up time was 58.4 months (SD ± 12.5). Univariate analysis of outcomes demonstrated no significant difference between residents and attendings in complications and reoperations rate (p = 0.690, p = 0.388). Sub-analysis by fracture pattern (Lauge-Hansen classification) and the number of malleoli involved and fixated demonstrated similar outcomes. surgery time was significantly longer in the resident group (p < 0.001).

CONCLUSION

The current study demonstrates that ankle fracture surgery can be performed by trained orthopaedic surgery residents, with similar results and complication rates as surgery performed by fellowship-trained attendings. These findings provide valuable insights into surgical autonomy in residency and its role in modern clinical training and surgical education.

LEVEL OF EVIDENCE

Level III - retrospective cohort study.

Patellar Fracture Surgery Performed Autonomously by Residents, Yields Similar Short-Term Outcomes to Surgery Performed by Fellowship-Trained Surgeons

BACKGROUND

Open reduction and internal fixation are the gold-standard treatment for displaced patellar fractures. The current literature remains inconclusive on the relationship between resident participation in the operating room and optimal patient outcomes. We hypothesize that surgeries performed solely by residents, without attending supervision, can provide similar outcomes to those performed by fellowship-trained orthopedic surgeons, providing new insights into the relationship between resident autonomy and surgical outcomes in the field of orthopedic trauma.

METHODS

A tertiary trauma center cohort was retrospectively reviewed for all surgically treated patellar fractures between 2015 and 2020. The cohort was divided into 2 groups: patients operated by residents and patients operated by orthopedic trauma specialists. Demographics, surgical parameters, and radiographs were compared between the groups to evaluate complications and reoperation rates, radiographic outcomes (such as hardware failure, or loss of reduction), and clinical outcomes (including residual pain, painful hardware, decreased range of motion, and infections).

RESULTS

A total of 129 patellar fractures were included in the study. Demographics and ASA were similar between the groups. There were no significant differences in complications (p = 0.900) or reoperation rates (p = 0.817), with an average follow-up time of 8 months (SD ± 5.3). Residents had significantly longer surgery duration (p =0.002). However, the overall length of stay was shorter in the resident group (p < 0.001).

CONCLUSION

The study shows patellar fracture surgery performed by adequately trained residents can provide similar outcomes to those performed by fellowship-trained orthopaedic trauma surgeons. These findings highlight the significance of surgical autonomy in residency and its role in contemporary surgical education.

Impact of Resident Involvement on 30-Day Postoperative Outcomes in Orthopedic Shoulder Surgery

The literature concerning resident involvement in shoulder surgery is limited. The purpose of this study was to examine whether resident involvement across all orthopedic shoulder surgeries is associated with adverse 30-day outcomes. Utilizing the American College of Surgeons National Surgical Quality Improvement Program database, patients who underwent shoulder surgery with or without a resident present were analyzed. Independent t-test and chi-square or Fischer's exact test were used appropriately. A logistic regression model was used to calculate adjusted odds ratios. This study examined 5,648 patients: 3,455 patients in the "Attending alone" group and 2,193 in the "Attending and resident in the operating room" group. Resident presence in the operating room was not associated with increased complications, except for bleeding transfusions (OR 1.71, CI 1.32-2.21, P ≤ 0.001). This study demonstrates that resident involvement in orthopedic shoulder surgery does not present an increased risk for 30-day complications when compared to surgeries performed with the attending surgeon alone.

Resident involvement in hand and upper extremity surgery: An analysis of 30-day complications

Background

Rotations in hand and upper extremity surgery are a core component of the Orthopaedic and Plastic Surgery resident training curriculums. This study compares short-term outcomes in hand and upper extremity procedures with and without resident involvement.

Methods

The National Surgical Quality Improvement Program database was queried from years 2005-2012 for all procedures distal to the shoulder. Patients were stratified based on whether a resident scrubbed for the procedure. Outcome measures were 30-day mortality, reoperation rate, minor complications, major complications, and length of stay (LOS). Chi-squared tests were used to determine significant variables. Significant variables were included in a binomial multivariate logistic regression model.

Results

A total of 7697 patients were included in the study. Of those, 4509 (59 %) had no resident, and 3188 (41 %) had a resident. Patients with resident involvement were less likely to be Caucasian, ASA classification 3 or higher, and outpatient. Cohorts were similar with respect to age, sex, and emergent status. Operative time was 15 min longer in resident cases. Work relative value units were higher in resident cases. In the multivariate logistic regression model, resident involvement had no statistically significant impact on LOS, mortality, reoperation rate, minor complications, or major complications. Subgroup analysis showed increased odds of superficial surgical site infections in resident cases, although this was statistically insignificant (OR 1.35, p = 0.24).

Conclusions

Hand and upper extremity procedures with resident involvement do not have any increase in overall adverse short-term outcomes. In appropriately selected cases, residents can participate without compromising patient safety.

Does the type of anesthesia (regional vs. general) represent an independent predictor for in-hospital complications in operatively treated malleolar fractures? A retrospective analysis of 5262 patients

PURPOSE

The impact of the type of anesthesia (regional vs. general anesthesia) on in-hospital complications in ankle fractures has not been thoroughly studied yet. Identifying factors that place patients at risk for complications following ankle fractures may help reduce their occurrence. The primary goal of this study was (1) to describe the cohort of patients and (2) to evaluate independent risk factors for complications during hospitalization.

METHODS

We analyzed patients from 2005 to 2019 with an operatively treated isolated fracture of the medial or lateral malleolus using a prospective national quality measurement database. Patients were selected based on international classifications (ICD) and national procedural codes (CHOP). Uni- and multivariate analysis were applied.

RESULTS

In total, we analyzed 5262 patients who suffered a fracture of the malleolus; 3003 patients (57%) had regional and 2259 (43%) general anesthesia. Patients with regional anesthesia were significantly older (51 vs. 46 years), but healthier (23 vs. 28% comorbidities) than patients who received general anesthesia. The in-hospital complication rate was not significantly lower in regional anesthesia (2.2% vs 3.0%). The type of anesthesia was not an independent predictor for complications while controlling for confounders.

CONCLUSION

Type of anesthesia was not an independent predictor of complications; however, higher ASA class, age over 70 years, fracture of the medial versus lateral malleolus, longer preoperative stay, and duration of surgery were significant predictors of complications. Patient and procedure characteristics, as well as changes in medical care and epidemiological changes along with patient requests, influenced the choice of the type of anesthesia.

Total elbow arthroplasty cases involving orthopaedic residents do not affect short-term postoperative complications

Background

Impact of resident participation on short-term postoperative outcomes after total elbow arthroplasty has not been studied. The aim was to investigate whether resident participation affects postoperative complication rates, operative time, and length of stay.

Methods

The American College of Surgeons National Surgical Quality Improvement Program registry was queried from 2006 to 2012 for patients undergoing total elbow arthroplasty. A 1:1 propensity score match was performed to match resident cases to attending-only cases. Comorbidities, surgical time, and short-term (30-day) postoperative complications were compared between groups. Multivariate Poisson regression was used to compare the rates of postoperative adverse events between groups.

Results

After propensity score match, 124 cases (50% with resident participation) were included. Adverse event rate after surgery was 18.5%. On multivariate analysis, there were no significant differences between attending-only cases and resident involved cases, with regards to short-term major complications, minor complications, or any complications (all p > 0.071). Total operative time was similar between cohorts (149.16 vs. 165.66 min; p = 0.157). No difference was observed in the length of hospital stay (2.95 vs. 2.6 days), p = 0.399.

Discussion

Resident participation during total elbow arthroplasty is not associated with increased risk for short-term medical or surgical postoperative complications or operative efficiency.

Resident and Fellow Participation Does Not Affect Short-Term Postoperative Complications After Distal Radius Fracture Fixation

Background  Complications after open reduction internal fixation (ORIF) for distal radius fractures (DRF) are well documented, but the impact of trainee involvement on postoperative outcomes has not been studied. Questions  Does trainee involvement affect postoperative complication rates and length of hospital stay? Methods  The American College of Surgeons National Surgical Quality Improvement Program was queried from 2006 to 2012 for patients undergoing DRF ORIF. A 1:1 propensity score matched resident/fellow involved cases to attending-only cases. Demographics, length of stay, and postoperative complications were compared between the two groups. Logistic regression was used to evaluate independent predictors of adverse events and to evaluate cases with and without trainee involvement. Results  Overall, 3,003 patients underwent DRF ORIF from 2006 to 2012. After matching, 1,150 cases (50% with resident/fellow involvement) were included. The overall rate of adverse events was 4.4% (46/1,050). There were no significant differences in the short-term complication rate in trainee-involved (2.3%) versus attending-only cases (3.9%) ( p  = 0.461). For ORIF of DRF, there were no significant differences, between attending-only cases and resident/fellow-involved cases, with regard to short-term major complications ( p  = 0.720) or minor complications ( p  = 0.374). Length of hospital stay was similar between cohorts (1.22 vs. 0.98 days) ( p  = 0.723). On multivariate analysis, trainee involvement was not an independent predictor of minor, major, or any complication after DRF fixation after controlling for multiple independent factors (all p  > 0.364). Discussion  Trainee participation in DRF ORIF is not associated with increased risk of short-term (30 days) medical or surgical postoperative complications. Level of Evidence  This is a Level IV case-control study.

Association of Diabetes Mellitus With Postoperative Complications and Mortality After Non-Cardiac Surgery: A Meta-Analysis and Systematic Review

BACKGROUND

Although a variety of data showing that diabetes mellitus (DM) (Type 1 or Type 2) is associated with postoperative complication, there is still a lack of detailed studies that go through the specific diabetic subgroups. The goal of this meta-analysis is to assess the relationship between DM and various complications after non-cardiac surgery.

METHODS

We searched articles published in three mainstream electronic databases (PubMed, EMBASE, Web of science) before November, 2020. A random effects model was conducted since heterogeneity always exist when comparing results between different types of surgery.

RESULTS

This paper included 125 studies with a total sample size of 3,208,776 participants. DM was a risk factor for any postoperative complication (Odds ratio (OR)=1.653 [1.487, 1.839]). The risk of insulin-dependent DM (OR=1.895 [1.331, 2.698]) was higher than that of non-insulin-dependent DM (OR=1.554 [1.061, 2.277]) for any postoperative complication. DM had a higher risk of infections (OR=1.537 [1.322, 1.787]), wound healing disorders (OR=2.010 [1.326, 3.046]), hematoma (OR=1.369 [1.120, 1.673]), renal insufficiency (OR=1.987 [1.311, 3.013]), myocardial infarction (OR=1.372 [0.574, 3.278]). Meanwhile, DM was a risk factor for postoperative reoperation (OR=1.568 [1.124, 2.188]), readmission (OR=1.404 [1.274, 1.548]) and death (OR=1.606 [1.178, 2.191]).

CONCLUSIONS

DM is a risk factor for any postoperative complications, hospitalization and death after non-cardiac surgery. These findings underscore the importance of preoperative risk factor assessment of DM for the safe outcome of surgical patients.

The July Effect in Podiatric Medicine and Surgery Residency

The period when medical students begin residency in teaching hospitals throughout the United States heralds a period known in the medical community as the "July Effect." Though several sentinel studies associated this timeframe with an increase in medical errors, residencies since demystified this phenomenon within their respective specialty. This study aims to evaluate the presence of the July Effect in a podiatric medicine and surgery residency program. A retrospective chart review was conducted, comparing patient demographics and surgical outcomes including length of stay, operative time and readmission rate between the first (July, August, September) and fourth (April, May June) quarters of the academic year from 2014-2019. A total of 206 patients met the inclusion criteria, where 99 received care in the first, resident-naïve, quarter and 107 received care in the fourth, resident-experienced, quarter. No difference in patient demographics including sex, body mass index, or comorbidity index was appreciated between both quarters (p<0.05). Those patients who underwent soft tissue and bone debridements, digital, forefoot, midfoot and rearfoot amputations experienced no statistically significant difference in length of stay, operative time, or readmission rate between both quarters (p<0.05). The results of this study did not support the presence of the July Effect in our foot and ankle surgery residency. Future studies can further explore this phenomenon by examining patients admitted following traumatic injury or elective procedures. Moreover, this study shows the curriculum employed at our program provides sufficient support, guidance, and resources to limit errors attributed to the July Effect.

Resident Level Involvement Affects Operative Time and Surgical Complications in Lower Extremity Fracture Care

OBJECTIVE

The purpose of this study is to evaluate the effect of resident participation on operative time and surgical complications in isolated lower extremity fracture care.

SETTING

Patients who were treated at teaching hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program database.

PARTICIPANTS

A total of 2,488 patients who underwent surgical fixation of isolated hip fractures, femoral or tibial shaft fractures, and ankle fractures.

DESIGN

Patients were stratified by surgical procedure and post-graduate year (PGY) of the resident involved. Total operative time and surgical complications were analyzed with respect to resident participation and seniority. Multivariable logistic regression analyses were used to adjust for potential confounders including case complexity, wound class, and patient comorbidity burden.

RESULTS

As PGY level increased, operative time increased for each procedure. The odds for a deep surgical site infection decreased as resident seniority increased, but the odds for wound dehiscence increased as resident seniority increased. We found no difference in the incidences of superficial infections or return to the OR with respect to PGY level. Academic quarter within the academic year did not correlate with any of the surgical complications. Furthermore, when cases performed with residents were compared to those performed without residents, there was no increased risk of superficial infections, deep infections, or return to the OR.

CONCLUSIONS

This nationally representative dataset demonstrates that operative times for lower extremity orthopedic trauma increased as resident seniority increased. Additionally, senior resident participation was associated with increased wound dehiscence, whereas junior resident participation was associated with an increased risk of deep surgical site infections. However, there was no associated "July effect" for residents at any level of training and there was no increased risk for surgical site infections or return to the OR in cases involving resident participation.

Does Resident Participation in the Surgical Fixation of Hip Fractures Increase Operative Time or Affect Outcomes?

BACKGROUND

Surgical fixation of hip fractures is a common procedure at teaching hospitals with resident support and in community hospitals.

OBJECTIVE

We evaluated to what extent participation by residents in hip fracture fixation affects operative times or outcomes.

SETTING

Operations were performed by three surgeons who operate at a teaching hospital with resident support, and at a community hospital without residents in the same metropolitan area.

PARTICIPANTS

We performed a retrospective analysis of operative time and early post-operative outcomes on a series of 314 patients with hip fractures (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association A1-3, B1-3) treated with surgical fixation between April 2012 and March 2015; 177 patients at the community hospital, and 137 at the teaching hospital.

METHODS

Multivariate regression assessed the effect of hospital type, adjusting for age, gender, American Society of Anesthesiologist classification, and Charlson comorbidity index.

RESULTS

We found lower median operative time at the community hospital than the teaching hospital (46 minutes, 95% confidence interval [CI] = [43, 52] versus 75 minutes, 95% CI = [70, 81]) and lower estimated blood loss (177.3 mL, 95% CI=[158.6, 195.1] versus 234.8 mL, 95% CI = [196.4, 273.6]), but no differences in transfusion requirement, length of stay, or discharge to skilled nursing facility. Adjusted odds ratio for thirty-day mortality at the teaching hospital was 5.44 (95% CI = [1.22, 24.1]).

CONCLUSION

We found longer operative times and elevated estimated blood loss with resident involvement in surgical fixation of hip fractures. There was a difference in 30-day mortality between the groups, although this cannot simply be attributed to resident involvement as there are many other factors related to mortality.

Independent Risk Factors for Impaired Early Outcome after Isolated Ankle Fracture - A Multivariate Analysis and Prognostic Models

BACKGROUND

Ankle fractures are common operative indications in orthopedic surgery. Their incidence is increasing.

OBJECTIVES

To identify independent risk factors and to develop prognostic models for the prediction of prolonged length of hospital stay (LOS) and the onset of postoperative complications.

MATERIALS AND METHODS

This is a single-center, retrospective, observational study analyzing data of 154 consecutive, isolated, surgically treated ankle fractures. Multivariate binary logistic regression analysis was applied to identify significant independent risk factors. The validity and clinical applicability of the developed prognostic models was assessed with ROC-curve analysis (ROC: Receiver Operating Characteristic). Internal validation of prognostic models was performed with randomized backwards bootstrapping.

RESULTS

The median LOS was 7 days. 50 patients (33%) had a longer LOS. 13% of operated patients had a postoperative complication (n = 20). Independent preoperative risk factors for prolonged length of stay were leukocytosis (p = 0.020; OR: 1.211), an increased CRP-level (p = 0.005; OR: 1.901), as well as a bi- (p = 0.002; OR: 15.197) or trimalleolar (p = 0.001; OR: 10.678) fracture type. Immediate operative therapy was an independent beneficial factor (p < 0.001; OR: 0.070). The onset of complications was associated significantly with diabetes mellitus (p = 0.004; OR: 9.903) and an elevated ASA score (p = 0,004; OR: 3.574). The developed prognostic models for the prediction of prolonged LOS (AUROC: 0.736) and postoperative complications (AUROC: 0.724) had a good clinical validity and were internally validated.

CONCLUSION

The current data pronounce the importance of preoperative laboratory works. Furthermore, co-morbidities play a major role in the prognosis of outcome. The developed prognostic models are able to reliably predict the outcome and enable the preoperative identification of high-risk patients.

Longer Operative Time Is Independently Associated With Surgical Site Infection and Wound Dehiscence Following Open Reduction and Internal Fixation of the Ankle

Background: Little is known regarding the association of operative time with adverse events following foot and ankle surgery. This study tests whether greater operative time is associated with the occurrence of adverse events following open reduction and internal fixation (ORIF) of the ankle. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for cases of ankle ORIF (primary CPT codes 27766, 27769, 27792, 27814, 27822, 27823) performed during 2005-2016. Operative time was tested for association with the occurrence of adverse events with controls for baseline characteristics and primary CPT code. Results: A total of 20 591 procedures met inclusion/exclusion criteria. The average (±SD) operative time was 75.7 (±37.3) minutes and varied by baseline characteristics and primary CPT code. After controlling for these factors, a 15-minute increase in operative time was associated with an 11% increase in risk for developing surgical site infection (SSI; relative risk [RR]: 1.11; 95% CI: 1.06-1.16), 20% for wound dehiscence (RR: 1.20; 95% CI: 1.11-1.29), 10% for anemia requiring transfusion (RR: 1.10; 95% CI: 1.04-1.17), 60% for cerebrovascular accident (RR: 1.60; 95% CI: 1.17-2.18), 14% for unplanned intubation (RR: 1.14; 95% CI: 1.03-1.26), and 7% for extended length of hospital admission (RR: 1.07; 95% CI: 1.05-1.09). Conclusion: Operative time is linearly and independently associated with the risks for SSI, wound dehiscence, and other adverse events following ORIF of the ankle. Efforts should be implemented to safely minimize operative duration without compromising the technical components of the procedure. Levels of Evidence: Therapeutic, Level IV.

Quantifying the Opportunity Cost of Resident Involvement in Academic Orthopaedic Sports Medicine: A Matched-Pair Analysis

PURPOSE

To quantify the cost of resident involvement in academic sports medicine by examining differences in operative time, relative value units (RVUs) per case, and RVUs per hour between attending-only cases and cases with resident involvement.

METHODS

A retrospective analysis of common sports medicine procedures identified by Current Procedural Terminology code was performed using data from the American College of Surgeons National Surgical Quality Improvement Program database from 2006 to 2015. Matched cohorts were generated based on demographic variables, comorbidities, preoperative laboratory values, and surgical procedures. Bivariate analysis examined mean differences in operative time, RVUs per case, and RVUs per hour between attending-only cases and cases with resident involvement. A cost analysis was performed to quantify differences in RVUs generated per hour in terms of dollars per case.

RESULTS

A total of 14,840 attending-only cases and 2,230 resident-involved cases were used to generate 2 matched cohorts (N = 4,460). Resident cases had greater mean operative times than attending-only cases, with operative time increasing as residents became more senior (P < .01). Residents participated in cases with larger mean RVUs per case (P < .01). Cases with lone attendings showed greater RVUs per hour (P < .01). The cost of resident involvement increased nearly 8-fold from postgraduate year 1 to postgraduate year 6 residents ($25.70 vs $200.07).

CONCLUSIONS

In academic sports medicine, the involvement of resident physicians increases operative time. The associated decrease in attending physician efficiency in RVUs per hour equates to an average cost per case of $159.18, with costs increasing as residents become more senior.

LEVEL OF EVIDENCE

Level III, retrospective comparative trial.

Factors Associated With Wound- and Implant-Related Complications After Surgical Treatment of Ankle Fractures

We have described the epidemiology of complications after surgical treatment of ankle fractures and assessed which factors are associated with the most frequent complications. We conducted a retrospective cohort study at 2 level 2 and 1 level 1 trauma center in a single trauma region in the Netherlands. The study variables were collected from the electronic medical patient records; all ankle fractures were classified using the Lauge-Hansen classification, and the complications were recorded. A total of 989 patients were included from 3 hospitals, with 173 complications in 156 patients (15.8%). The most frequent complication was wound related, occurring in 101 patients (10.2%). Implant-related complications occurred in 44 patients (4.4%). Other complications, such as cast pressure spots, posttraumatic dystrophy, nonunion, impingement, and pneumonia occurred in 28 patients (2.8%). The 2 most important complications were further analyzed for risk factors. Multivariate analysis showed the risk factors for wound-related complications were advanced age, increased American Society of Anesthesiologists classification, smoking, right side symptomatic, open fracture, and initial external fixation. Most implant-related complications were caused by malreduction (n = 22) or untreated syndesmotic injury (n = 19). Malreduction was associated with supination eversion fractures (p = .059), and untreated syndesmotic injury occurred more often with pronation external rotation fractures (p < .001). The most frequent complications after ankle fracture surgery were wound- and implant-related complications. Postoperative wound-related complications were multifactorial and dependent on a combination of trauma-, patient-, and treatment-related factors. In contrast, implant-related complications resulted from the interaction between the fracture type and subsequent surgical treatment.