Impact of Resident Involvement on Orthopaedic Surgery Outcomes: An Analysis of 30,628 Patients from the American College of Surgeons National Surgical Quality Improvement Program Database

Comparison of Surgical Outcomes After Posterior Decompression by Junior or Senior Surgeons for Patients With Cervical Ossification of the Posterior Longitudinal Ligament: Results From Retrospective Multicenter Cohort Study

STUDY DESIGN

Retrospective multicenter study.

OBJECTIVES

To investigate surgical outcomes following posterior decompression for cervical ossification of the posterior longitudinal ligament (OPLL) when performed by board-certified spine (BCS) or non-BCS (NBCS) surgeons.

METHODS

We included 203 patients with cervical OPLL who were followed for a minimum of 1 year after surgery. Demographic information, medical history, and imaging findings were collected. Clinical outcomes were assessed preoperatively and at the final follow-up using the Japanese Orthopedic Association (JOA) score and the visual analog scale (VAS) for the neck. We compared outcomes between BCS surgeons, who must meet several requirements, including experience in more than 300 spinal surgeries, and NBCS surgeons.

RESULTS

BCS surgeons performed 124 out of 203 cases, while NBCS surgeons were primary in 79 cases, with 73.4% were directly supervised by a BCS surgeon. There was no statistically significant difference in surgical duration, estimated blood loss, and perioperative complication rates between the BCS and NBCS groups. Moreover, no statistically significant group differences were observed in each position of the C2-7 angle and cervical range of motion at preoperation and the final follow-up. Preoperative and final follow-up JOA scores, VAS for the neck, and JOA score recovery rate were comparable between the two groups.

CONCLUSIONS

Surgical outcomes, including functional recovery, complication rates, and cervical dynamics, were comparable between the BCS and NBCS groups. Consequently, posterior decompression for cervical OPLL is considered safe and effective when conducted by junior surgeons who have undergone training and supervision by experienced spine surgeons.

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.

Operating room organization and surgical performance: a systematic review

BACKGROUND

Organizational factors may influence surgical outcomes, regardless of extensively studied factors such as patient preoperative risk and surgical complexity. This study was designed to explore how operating room organization determines surgical performance and to identify gaps in the literature that necessitate further investigation.

METHODS

We conducted a systematic review according to PRISMA guidelines to identify original studies in Pubmed and Scopus from January 1, 2000 to December 31, 2019. Studies evaluating the association between five determinants (team composition, stability, teamwork, work scheduling, disturbing elements) and three outcomes (operative time, patient safety, costs) were included. Methodology was assessed based on criteria such as multicentric investigation, accurate population description, and study design.

RESULTS

Out of 2625 studies, 76 met inclusion criteria. Of these, 34 (44.7%) investigated surgical team composition, 15 (19.7%) team stability, 11 (14.5%) teamwork, 9 (11.8%) scheduling, and 7 (9.2%) examined the occurrence of disturbing elements in the operating room. The participation of surgical residents appeared to impact patient outcomes. Employing specialized and stable teams in dedicated operating rooms showed improvements in outcomes. Optimization of teamwork reduced operative time, while poor teamwork increased morbidity and costs. Disturbances and communication failures in the operating room negatively affected operative time and surgical safety.

CONCLUSION

While limited, existing scientific evidence suggests that operating room staffing and environment significantly influences patient outcomes. Prioritizing further research on these organizational drivers is key to enhancing surgical performance.

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.

Resident Involvement in Shoulder-Stabilization Procedures Is Not Associated With an Increased Risk of 30-Day Postoperative Complications

Purpose

To examine the 30-day postoperative outcomes of resident involvement in shoulder-stabilization surgical procedures using the American College of Surgeons National Surgical Quality Improvement database.

Methods

We conducted a retrospective review of the National Surgical Quality Improvement database for all shoulder-stabilization procedures from 2010 to 2018. Procedures included arthroscopic Bankart, arthroscopic Bankart with SLAP repair, arthroscopic Bankart with Remplissage, open Bankart, anterior bone block, posterior bone block, Latarjet coracoid process transfer, and capsular shift/capsulorrhaphy for multidirectional instability. Data included preoperative demographics, comorbidities, and 30-day postoperative outcomes. Cases were categorized into 2 groups: "attending alone" and "attending and resident." Statistical analysis comparing groups on demographics and comorbidities included independent t-test for continuous variables and Pearson χ2 or Fischer exact for categorical variables. A logistic regression model including propensity score was used to calculate adjusted odds ratio for outcomes.

Results

A total of 3,954 patients undergoing shoulder-stabilization procedures were included in the study and 28.8% of patients had a resident involved in their procedure. Residents were more likely to be involved in procedure for patients who were of minority ethnicity (P < .001), a lower body mass index (P < .001) and less likely to have a history of chronic obstructive pulmonary disease (P = .029). Resident involvement resulted in statistically significant longer total operation time (91 vs 85 minutes, P < .001). In terms of postsurgical outcomes, complication rates were low for both groups (∼0.8%). Resident involvement was not associated with any significant increase in 30-day postsurgical complications.

Conclusions

Our results show that resident involvement in shoulder-stabilization surgery is associated with a significant increase in operative time without any significant increase in 30-day postsurgical complications.

Level of Evidence

Level III, retrospective comparative study.

The Effect of Resident Involvement in Hip Fracture Surgery: An Analysis of a Single Institution Before and After the Addition of an Orthopaedic Surgical Residency

INTRODUCTION

Hip fractures are common injuries that are associated with serious morbidity/mortality in the elderly and represent a substantial financial burden to healthcare systems. Previous studies demonstrated that resident involvement in orthopaedic surgeries is associated with increased surgical time and cost, with equivocal or worse outcomes. This study evaluated outcomes of hip fracture surgery at one institution, before and after the introduction of an orthopaedic residency program.

METHODS

A retrospective chart review divided patients who underwent hip fracture surgery between January 2015 and January 2018 into two groups based on resident involvement. Outcomes including surgical time, length of stay (LOS), readmission rate, and direct/indirect costs were compared as were the American Society of Anesthesiologists physical status score and procedure conducted.

RESULTS

Six hundred sixty-two hip fracture surgeries were performed in 36 months. Residents were engaged in 303 cases (45.8%) with no notable differences in the two groups regarding American Society of Anesthesiologists score, procedure conducted, or readmission rate. With resident involvement, surgical time was significantly longer (91.2 versus 78.9 minutes, P-value = 0.004), whereas LOS was significantly shorter (5.2 versus 5.6 days, P-value = 0.003). Finally, there were significant reductions in direct costs (8% reduction; P < 0.001) and OR implant costs (12% reduction; P < 0.001), but significant increase in indirect costs (7% increase; P < 0.001).

DISCUSSION

Surgical experience is critical in orthopaedic training. There are concerns regarding potential negative effects of resident involvement on surgical outcomes and healthcare costs. While resident involvement was associated with slightly increased surgical times and indirect costs, it also led to decreased LOS and direct costs. We believe this is the first study to compare patient outcomes at one institution before and after resident involvement. Our findings demonstrated, compared with attendings alone, resident involvement resulted in an overall improvement rather than compromise in patient care.

Learning Effect for Large Joint Diagnostic Aspirations With Fluoroscopy and Ultrasound

OBJECTIVE

The first objective was to identify whether increased experience, gauged by number of procedures performed posttraining, is correlated with greater likelihood of obtaining joint fluid in diagnostic aspirations. The second objective was to identify whether trainee involvement at the time of procedure affected the success rate of the procedure (which in this case was obtaining fluid on aspiration).

DESIGN

This was a retrospective analysis of fluoroscopic- and ultrasound-guided large joint aspirations. Logarithmic fit was performed to identify the presence of a learning curve to the successful attainment of fluid with experience. Logistic regression analysis was used to identify whether trainee presence for a procedure affected fluid attainment.

RESULTS

Ultrasound did not demonstrate a significant fit to the logarithmic curve ( P = 0.447), whereas fluoroscopy did ( P < 0.001), indicative of a learning curve for fluoroscopy. After adjusting for covariates, joint fluid was successfully attained at a similar rate whether trainees were present or not. Significant independent factors related to successful joint fluid attainment were image guidance technique ( P = 0.001), body mass index ( P = 0.032), and joint aspirated (overall P < 0.001).

CONCLUSION

There was a statistically significant learning curve for fluoroscopic-guided joint aspirations, but not with ultrasound guidance. Trainee involvement did not affect the success rate of joint aspirations.

Quantifying the Opportunity Cost of Resident Involvement in Academic Orthopedic Shoulder Arthroplasty: A Matched - Pair Analysis

Background

There is minimal work defining the economic impact of resident participation in shoulder arthroplasty. Thus, this study quantified the opportunity cost of resident participation in total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) by determining differences in operative time, relative value units (RVUs)/hour, and RVUs/case.

Methods

A retrospective analysis of shoulder arthroplasty procedures were identified from the ACS-NSQIP database from 2006 to 2014 using CPT codes. Demographic, comorbidity, preoperative laboratory data and surgical procedure were used to develop matched cohorts. Mean differences in operative time, RVUs/case and RVUs/hour between attending-only (AO) cases and cases with resident involvement (RI) were examined. Cost analysis was performed to identify differences in RVUs generated per hour in dollars/case.

Results

A total of 1786 AO and 1102 RI cases were identified. With the exception of PGY-3 and PGY-4 cases, RI cases had lower mean operative times compared to AO cases. The cost of RI was highest for PGY-3 ($199.87 per case) and PGY-4 ($9 .2 9) residents with all other postgraduate years providing a cost reduction.

Discussion

Involvement of residents was associated with shorter operative times leading to a savings of $29.64 per case. Involvement of intermediate-level (PGY-3) residents were associated with increased costs that ultimately decreased as residents became more senior.

The impact of surgical trainee involvement in total knee arthroplasty: a systematic review of surgical efficacy, patient safety, and outcomes

PURPOSE

Trainee involvement in patient care has raised concerns about the potential risk of adverse outcomes and harming patients. We sought to analyze the impact and potential consequence of surgical trainee involvement in total knee arthroplasty (TKA) procedures in terms of surgical efficacy, patient safety, and functional outcomes.

METHODS

We systematically reviewed Medline/PubMed, EMBASE, the Cochrane library, and Scopus databases in April 2021. Eligible studies reported on the impact of trainee participation in TKA procedures performed with and without such involvement.

RESULTS

Twenty-three publications met our eligibility criteria and were included in our study. These studies reported on 132,624 surgeries completed on 132,416 patients. Specifically, 23,988 and 108,636 TKAs were performed with and without trainee involvement, respectively. The mean operative times for procedures with (n = 19,573) and without (n = 94,581) trainee involvement were 99.77 and 85.05 min, respectively. Both studies that reported data on cost of TKAs indicated a significant increase (p < 0.001) associated with procedures completed by teaching hospitals compared to private practices. Mean overall complication rates were 7.20% and 7.36% for TKAs performed with (n = 9,386) and without (n = 31,406) trainees. Lastly, the mean Knee Society Scale (KSS) knee scores for TKAs with (n = 478) and without (n = 806) trainee involvement were similar; 82.81 and 82.71, respectively.

CONCLUSION

Our systematic review concurred with previous studies that reported trainee involvement during TKAs increases the mean operative time. However, the overall complication rates and functional outcomes were similar. Larger studies with a better methodology and higher level of evidence are still needed for a resolute conclusion.

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.

Does the Surgical Assistant Influence Perioperative Outcomes Surrounding Cubital Tunnel Surgery?

Background: Ulnar neuropathy at the elbow is the second most common upper extremity compressive neuropathy and surgical treatment often involves surgical trainee involvement. The primary aim of this study is to determine the effect of trainees and surgical assistants on outcomes surrounding cubital tunnel surgery. Methods: This retrospective study included 274 patients with cubital tunnel syndrome who underwent primary cubital tunnel surgery at two academic medical centres between 1 June 2015 and 1 March 2020. The patients were divided into four main cohorts based on primary surgical assistant: physician associates (PA, n = 38), orthopaedic or plastic surgery residents (n = 91), hand surgery fellows (n = 132), or both residents and fellows (n = 13). Exclusion criteria included patient age <18 years, revision surgery as the index procedure, prior traumatic ulnar nerve injury and concurrent procedures not related to cubital tunnel surgery. Demographics, clinical variables and perioperative findings were collected through chart reviews. Univariate and bivariate analyses were performed, and p < 0.05 was considered significant. Results: Patients in all cohorts had similar demographic and clinical characteristics. There was a significantly higher rate of subcutaneous transposition in the PA cohort (39.5% PA vs. 13.2% Resident vs. 19.7% Fellow vs. 15.4% Resident + Fellow). Presence of surgical assistants and trainees had no association with length of surgery, complications and reoperation rates. Although male sex and ulnar nerve transposition were associated with longer operative times, no explanatory variables were associated with complications or reoperation rates. Conclusions: Surgical trainee involvement in cubital tunnel surgery is safe and has no effect on operative time, complications or reoperation rates. Understanding the role of trainees and measuring the effect of graduated responsibility in surgery is important for medical training and safe patient care. Level of Evidence: Level III (Therapeutic).

How dimensions can guide surgical planning and training: a systematic review of Kambin's triangle

OBJECTIVE

The authors sought to analyze the current literature to determine dimensional trends across the lumbar levels of Kambin's triangle, clarify the role of imaging techniques for preoperative planning, and understand the effect of inclusion of the superior articular process (SAP). This compiled knowledge of the triangle is needed to perform successful procedures, reduce nerve root injuries, and help guide surgeons in training.

METHODS

The authors performed a search of multiple databases using combinations of keywords: Kambin's triangle, size, measurement, safe triangle, and bony triangle. Articles were included if their main findings included measurement of Kambin's triangle. The PubMed, Scopus, Ovid, Cochrane, Embase, and Medline databases were systematically searched for English-language articles with no time frame restrictions through July 2022.

RESULTS

Eight studies comprising 132 patients or cadavers were included in the study. The mean ± SD age was 66.69 ± 9.6 years, and 53% of patients were male. Overall, the size of Kambin's triangle increased in area moving down vertebral levels, with L5-S1 being the largest (133.59 ± 4.36 mm2). This trend followed a linear regression model when SAP was kept (p = 0.008) and removed (p = 0.003). There was also a considerable increase in the size of Kambin's triangle if the SAP was removed.

CONCLUSIONS

Here, the authors have provided the first reported systematic review of the literature of Kambin's triangle, its measurements at each lumbar level, and key areas of debate related to the definition of the working safe zone. These findings indicate that CT is heavily utilized for imaging of the safe zone, the area of Kambin's triangle tends to increase caudally, and variation exists between patients. Future studies should focus on using advanced imaging techniques for preoperative planning and establishing guidelines for surgeons.

A comparison of in-hospital outcomes after elective anterior cervical discectomy and fusion in cases with and without Parkinson's Disease

Background

Following orthopedic surgery, patients with Parkinson's disease (PD) have been shown to have high rates of surgical complications, and some studies suggest that PD may be associated with greater risk for postoperative medical complications. As complication rates are critical to consider for elective surgery planning, the current study aimed to describe the association of PD with medical complications following anterior cervical discectomy and fusion (ACDF), the most commonly performed procedure to treat cervical degenerative pathology.

Methods

The 2008-2018 National Inpatient Sample database was queried for cases involving elective ACDF. Demographics and comorbidities were extracted using ICD codes. Cases were propensity matched based on demographic and comorbidity burden, and logistic regression was used to compare in-hospital complications between patients with and without PD.

Results

After weighting, a total of 1,273,437 elective ACDF cases were identified, of which 3948 (0.31%) involved cases with PD. After 1:1 propensity score matching by demographic and comorbidity variables, there were no differences between the PD and non-PD cohorts. Logistic regression models constructed for the matched and unmatched populations showed that PD cases have greater odds of in-hospital minor adverse events with no differences in odds of serious adverse events or mortality.

Conclusions

After matching for demographics and comorbidity burden, PD cases undergoing elective ACDF had slightly longer length of stay and greater risk for minor adverse events but had similar rates of serious adverse events and mortality. These findings are important for surgeons and patients to consider when making decisions about surgical intervention.

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.

Validation of a High-Fidelity Fracture Fixation Model for Skill Acquisition in Orthopedic Surgery Residents

OBJECTIVE

Simulation has become a widely accepted part of training and credentialing processes due to its ability to supplement technical skill acquisition outside of the operating room (OR). This project explores implementation of a bench-top simulation of open reduction with internal fixation (ORIF) as a cost-effective method for practicing and evaluating surgical skill.

DESIGN, SETTING, AND PARTICIPANTS

Participants ranging from intern to attending surgeon performed ORIF using a standard fixation set and a bovine or porcine tibia/radius model. Performance was recorded and scored by blinded reviewers based on a modified global rating scale (GRS), objective structured assessment of technical skills (OSATS) procedure-specific checklist, and critical-mistakes (CM) model. We calculated Fleiss' kappa for inter-rater reliability, Cronbach's alpha for internal consistency of scoring systems, and used univariate analysis to determine the ability of this model to discriminate between training levels. We also performed a normalized performance-versus-cost analysis to characterize perceived value of this simulation compared to other modalities.

RESULTS

Twenty subjects completed the fracture fixation exercise. Fleiss' kappa for all scoring systems indicated substantial inter-rater agreement (k = 0.81, 0.80, and 0.74 for GRS, OSATS, and CM, respectively). Internal consistency reliability for GRS and OSATS were high with Cronbach's alpha 0.96(95%CI 0.94-0.97) and 0.94(95%CI 0.91-0.96), respectively. Using a Kuskal-Wallis rank sum test, GRS, OSATS, and CM were found effective for measuring differences between resident levels (p < 0.001, p < 0.001, and p = 0.002, respectively). Qualitative valuation of the exercise indicated similar value for education compared to time spent in the OR and surgical skills labs.

CONCLUSIONS

This benchtop surgical simulation provides quantitative measurement of operative skills progression, increases trainee familiarity with ORIF principles, and permits targeted education by senior surgeons with the goal of training safe graduates. Procedure-specific checklist grading tools reliably differentiated between training levels with high internal validity. Implementing this model may decrease training costs and accelerate skill acquisition.

Effect of Fellow Involvement and Experience on Patient Outcomes in Spine Surgery

INTRODUCTION

Investigations in spine surgery have demonstrated that trainee involvement correlates with increased surgical time, readmissions, and revision surgeries; however, the specific effects of spine fellow involvement remain unelucidated. This study aims to investigate the isolated effect of fellow involvement on surgical timing and patient-reported outcomes measures (PROMs) after spine surgery and evaluate how surgical outcomes differ by fellow experience.

METHODS

All patients aged 18 years or older who underwent primary or revision decompression or fusion for degenerative diseases and/or spinal deformity between 2017 and 2019 at a single academic institution were retrospectively identified. Patient demographics, surgical factors, intraoperative timing, transfusion status, length of stay (LOS), readmissions, revision rate, and preoperative and postoperative PROMs were recorded. Surgeries were divided based on spine fellow participation status and occurrence in the start or end of fellowship training. Univariate and multivariate analyses compared outcomes across fellow involvement and fellow experience groups.

RESULTS

A total of 1,108 patients were included. Age, preoperative diagnoses, number of fusion levels, and surgical approach differed markedly by fellow involvement. Fellow training experience groups differed by patient smoking status, preoperative diagnosis, and surgical approach. On univariate analysis, spine fellow involvement was associated with extended total theater time, induction start to cut time, cut to close time, and LOS. Increased spine fellow training was associated with reduced cut to close time and LOS. On regression, fellow involvement predicted cut to close extension while increased fellow training experience predicted reduction in cut to close time, both independent of surgical factors and assisting residents or physician assistants. Transfusions, readmissions, revision rate, and PROMs did not differ markedly by fellow involvement or experience.

CONCLUSION

Spine fellow participation predicted extended procedural duration. However, the presence of a spine fellow did not affect long-term postoperative outcomes. Furthermore, increased fellow training experience predicted decreased procedural time, underscoring a learning effect.

AVAILABILITY OF DATA AND MATERIAL

The data sets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

LEVEL OF EVIDENCE

Level 3.

Does Surgical Trainee Participation Affect Infection Outcomes in Primary Total Knee Arthroplasty?

OBJECTIVE

To evaluate whether the involvement of surgeons-in-training was associated with increased infection rates, including both prosthetic joint infection (PJI) and surgical site infection (SSI), following primary total knee arthroplasty (TKA).

DESIGN

This was a retrospective review of outcomes following primary total knee arthroplasty. Surgeries were divided into two groups: (a) attending-only and (b) trainee-involved. Association with PJI and SSI were evaluated with univariate analysis and multivariate analysis to adjust for sex, age, body mass index (BMI), Charlson Comorbidity Index (CCI), year of surgery, operative time, and hospital/surgeon volume.

SETTING

A single, large North-American integrated healthcare system between January 1, 2014 and December 31, 2017.

PARTICIPANTS

A total of 12,664 primary TKAs with a minimum of one-year (mean of 2-years, range 1-4.5) follow-up were evaluated.

RESULTS

Residents and fellows were more likely to participate in cases with longer operative times (p<0.001) than the attending-only group. A significant difference existed on univariate analysis between the trainee-involved group and attending-only group for PJI incidence (p=0.015) but not for SSI (p=0.840). After adjusting for patient- and procedure-related features, however, neither PJI nor SSI were independently associated with trainee involvement (PJI: p=0.089; SSI: p=0.998).

CONCLUSIONS

Trainee participation did not directly correlate with increased infection risk, despite their association with longer-operative times and increased medical complexity. Further approaches to mitigating the risk of SSI and PJI for patients with increased comorbidities and in complex TKA cases, which demand longer operative times, are still required.

Orthopaedic residents' autonomy in hip fracture surgery: what is the effect on patient outcomes?

BACKGROUND

In the context of growing prevalence of hip fractures and hip fracture surgery in the elderly, it is unknown if surgical trainee autonomy in the operating room conflicts with optimal health care provision and safety of patients. 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 joint reconstruction fellowship-trained orthopaedic surgeons.

METHODS

A single-center cohort was retrospectively reviewed for all hip fracture cases, surgically treated with hemiarthroplasty or internal fixation during 2016. Data were analyzed and compared between surgery performed solely by post-graduate-year 4 to 6 residents, and surgery performed by trauma or joint replacement fellowship-trained surgeons. Demographics, time to surgery, and American Society of Anesthesiologists Physical Status Classification System (ASA), surgical parameters, preoperative and postoperative radiographs as well as primary (mortality, complications and revision surgery) and secondary outcome variables were collected and analyzed. Univariate analysis and Kaplan-Meier survival analysis were performed to evaluate outcomes.

RESULTS

Out of 478 cases, 404 (84.5%) were included in this study. Non-operative cases, techniques used solely by attending surgeons, such as total hip replacement, were excluded. The average follow-up time was 26.1 months (SD 10.9). Analysis of internal fixation and hemiarthroplasty groups demonstrated no significant difference between residents and attendings in complications (p = 0.353, 0.850, respectively), and mortality (p = 0.796, 0.734, respectively). In both groups, surgery time was significantly longer in the resident group (p < 0.001).

CONCLUSION

The current study demonstrates that hip fracture surgery performed by adequately trained orthopaedic surgery residents can provide similar results to surgery performed by fellowship-trained attendings.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

The Impact of Resident Involvement on Outcomes and Costs in Elective Hand and Upper Extremity Surgery

PURPOSE

The purpose of this study was to assess the impact of resident involvement on periprocedural outcomes and costs after common procedures performed at an academic hand surgical practice.

METHODS

A retrospective review was performed in all patients undergoing 7 common elective upper extremity procedures between January 2008 and December 2018: carpal tunnel release, distal radius open reduction and internal fixation (ORIF), trigger finger release, thumb carpometacarpal arthroplasty, phalanx closed reduction and percutaneous pinning, cubital tunnel release, and olecranon ORIF. The medical record was reviewed to determine the impact of surgical assistants (resident, fellow, or physician assistant) on periprocedural outcomes, periprocedural costs, and 1-year postoperative outcomes. The involvement of surgical trainees operating under direct supervision was compared with the entire operation performed by the attending surgeon with a physician assistant present.

RESULTS

A total of 396 procedures met the inclusion criteria. Analysis of the whole study sample revealed low rates of intraoperative complications, wound complications, medical complications, readmissions, and mortality. Subgroup analysis of carpal tunnel releases revealed significantly greater tourniquet times for residents compared with physician assistants (7 ± 2 min, 6 ± 1 min), as well as longer overall operating room times for residents compared to fellows or physician assistants (17 ± 5 min, 13 ± 3 min, 12 ± 3 min). Operating room times for distal radius ORIF were significantly greater among residents compared to fellows or physician assistants (68 ± 19 min, 57 ± 17 min, 56 ± 14 min). There were no differences in any other perioperative metrics or periprocedural costs for the trigger finger release or cubital tunnel release cohorts.

CONCLUSIONS

Resident involvement in select upper extremity procedures can lengthen operative times but does not have an impact on blood loss or operating room costs.

CLINICAL RELEVANCE

Surgeons should be aware that having a resident assistant slightly increases operative times in elective hand surgery.

Does Resident Participation Influence Surgical Time and Clinical Outcomes? An Analysis on Primary Bilateral Single-Staged Sequential Total Knee Arthroplasty

Background

Although several studies have indirectly compared teaching and nonteaching hospitals, results are conflicting, and evaluation of the direct impact of trainee involvement is lacking. We investigated the direct impact of resident participation in primary total knee arthroplasties (TKAs).

Material and methods

Fifty patients undergoing single-staged sequential bilateral primary TKAs were evaluated. The more symptomatic side was performed by the attending surgeon first, followed by the contralateral side performed by a chief resident under direct supervision and assistance of the same attending surgeon. Surgery was subdivided into 8 critical steps on both sides. The overall time and critical stepwise surgical time and short-term clinical outcomes were then compared between the 2 sides.

Results

The attending surgeon completed the surgery (skin incision to dressing) significantly faster than the resident (70.2 vs 96.9 minutes) by a mean of 26.7 minutes (P < .05) and was also faster in all steps. The most significant differences in time were in “exposure” (9.5 vs 16.5 minutes) and “closure” steps (13.2 vs 24.9 minites), all P < .001. Adverse events occurred in 7 patients; 5 of these resolved uneventfully. There were no significant differences in surgical complications, objective outcome scores, or patient satisfaction scores between both sides.

Conclusion

Resident participation in TKA increased operative time without jeopardizing short-term patient clinical outcomes, satisfaction, and complications. This may alleviate concerns from patients and policymakers about TKA in an academic setting. Surgical “exposure” and “closure” were the most prolonged steps for the residents, and they may benefit with more focus and/or simulation studies during training.

Effect of Resident and Fellow Involvement on Outcomes of Sarcoma Surgery: A NSQIP Database Cross-Sectional Study

Background

The complexity of sarcoma surgery often justifies surgical assistants of higher levels of academic training: senior residents, fellows, or co-surgeons. The association between the level of training of assistants and outcomes of these procedures has yet to be studied.

Methods

The Current Procedural Terminology (CPT) codes comprising the “core” procedures for musculoskeletal oncology fellowships were gathered. After CPTs primarily capturing nononcologic procedures were excluded, the National Surgical Quality Improvement Program (NSQIP) database was used to find procedures with these CPTs. The severity of complications was assessed using the Severity Weighting of Postoperative Adverse Events in Orthopedic Surgery (SWORD) score. Resident/fellow presence was analyzed both as a binary variable and stratified by level of training.

Results

In 159 cases meeting inclusion criteria, higher-level assistants were associated with increased rate of any complication (p=0.006) and greater need for transfusion (p=0.001) but also tended to be used in cases of longer duration (p=0.001) and with higher total work relative value units (wRVUs) (p=0.001). Multivariate analysis showed that while higher-wRVU procedures persisted as an independent predictor of increased complications (OR 1.028 per RVU unit, p=0.002), neither the presence nor level of training of assistants had an independent effect on complication rates. Other independent predictors of 30-day complications were treatment comorbidity (OR 3.433, p=0.010) and lower extremity location of the tumor (OR 4.393, p=0.006). Severity of complications did not differ between any of the groups on either univariate or multivariate analysis.

Conclusions

Trainees of higher levels of academic training tend to be present for longer, higher-complexity musculoskeletal oncology cases, but the overall severity of complications from these do not significantly differ from lower-risk cases without trainees. Orthopedic oncologists may reassure patients that the presence of trainees and co-surgeons is not only safe but it may also help reduce the severity of complications in more complex procedures.

Resident training does not influence the complication risk in total knee and hip arthroplasty

Background and purpose - Gaining experience in the surgery room during residency is an important part of learning the skills needed to perform arthroplasties. However, in practice, patients are often not fully comfortable with trainee involvement in their own surgery. Therefore, we investigated complications, revision rates, mortality, and operative time of orthopedic surgeons and residents as primary surgeon performing total knee arthroplasties (TKAs) or total hip arthroplasties (THAs).Patients and methods - In this multi-center retrospective cohort study, 3,098 TKAs and 4,027 THAs performed between 2007 and 2013 were analyzed. Complications, revisions, mortality, and operative time were compared for patients operated on by the orthopedic surgeon or a resident as primary surgeon. An additional analysis was performed to determine whether the complication risk was affected by the postgraduate year of the resident.Results - Orthopedic complication rates were similar (TKA: orthopedic surgeon: 10%, resident: 11%; THA: 9% and 8%), revision rates (TKA: 3% and 2%, THA: 3% and 2%), or mortality rates (TKA: 0.1% and 0.3%, THA: 0.2% and 0.3%). For both procedures a higher non-orthopedic complication rate was found in the resident group (TKA: 8% and 10%; p = 0.03, THA: 8% and 10%; p = 0.01) and a slightly longer operative time (TKA: mean difference 9.0 minutes (8%); THA: 11.3 minutes (11%)).Interpretation - Complications, revisions, and mortality were similar in TKAs or THAs performed by the resident as primary surgeon compared with surgeries performed by an orthopedic surgeon. This data can be used in teaching hospitals and may help to reassure patients.

Resident Involvement in Hip Arthroscopy Procedures Does Not Affect Short-Term Surgical Outcomes

Purpose

To evaluate whether the presence of residents in hip arthroscopy (HA) procedures affects short-term surgical outcomes.

Methods

The American College of Surgeons National Surgical Quality Improvement Program Database was used to identify patients who underwent HA from 2006 to 2012. Demographic and 30-day outcome variables were compared between cohorts of patients with and without residents. Multivariate logistic regression was used to identify whether resident involvement was an independent risk factor for adverse outcomes. Propensity score matching was performed to control for all demographic and intraoperative variables.

Results

A total of 869 patients (59.7% female) were included in this study, 626 of which reported data on resident involvement. Patients were mostly White (73.4% of cases without a resident, 51.8% with a resident, P < .05). Those with residents were younger (P = .016), had lower modified 5-item frailty index (mFI-5) scores (P = .028), and had fewer cardiac comorbidities (P = .008). There was no difference in diabetic status, dyspnea symptoms, history of chronic obstructive pulmonary disease, renal comorbidity, neurologic comorbidity, cumulative comorbidities, history of bleeding disorders, inpatient vs. outpatient treatment, preoperative functional status, smoking history, and steroid use for chronic conditions. There was no difference in all complications, operative time, length of stay, reoperation, readmission, wound complication, venous thromboembolism, blood transfusions, or sepsis. Propensity score match for demographic and intraoperative differences found no association between resident involvement and increased complications. Resident involvement was not an independent risk factor for all complications studied.

Conclusion

Resident involvement in HA procedures was not a risk factor for 30-day complications between 2006 and 2012. Resident involvement did not increase the risk of adverse outcomes, readmission, reoperation, or length of stay, nor did it significantly increase operative times.

The Role of the Resident Doctor in Orthopedics and Traumatology in a Large Hospital of the Unified Health System: What is the User's view?

Objective  To assess the knowledge of patients seen at a teaching hospital about the academic and professional training of the resident doctor in orthopedics and traumatology, as well as his area of expertise, and determine the perception of the patients of comfort and safety in relation to being assisted by the resident doctor at different stages of treatment.

Methods  A cross-sectional study was conducted with patients admitted to a large orthopedics hospital of the Brazilian Unified Health System (SUS, in the Portuguese acronym). Data were collected through the application of a questionnaire containing 19 objective questions that assessed sociodemographic parameters and the perception of the patient of the performance of the resident. The data were analyzed to assess the frequency of responses obtained.

Results  152 participants were evaluated, predominantly male (62.6%) and aged between 36 and 55 years old (41.3%). Only 43.3% were aware of the academic background of the resident. Patients reported feeling safer and more comfortable being assisted by the doctor together with the resident in the outpatient consultation (43.3%), in the nursing ward (39.3%) and during surgery (61%). As for the performance of the resident, 80.2% stated that the resident doctor improves communication between the patient and the main surgeon; however, only 11% said they would feel safe and comfortable being cared for exclusively by residents in the surgical environment, if allowed.

Conclusion  The participation of resident physicians in the care is well received by the patients if they are in the company of the attending physician. Patients identify residents as a facilitating bridge in the communication with attending physicians.

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.

Why Orthopaedic Residents Must Be Exposed to and Taught Value-Based Care: AOA Critical Issues

The shift to value-based care is changing the practice of medicine. In order to prepare our orthopaedic trainees to survive in a value-based health-care environment, we must expose them to and educate them about value-based programs. This creates both challenges and opportunities for training programs. Academic medical centers (AMCs) will need to carefully consider how to adopt value-based programs and agreements, and assess whether they need alternative facilities, partnerships, or processes in order to be successful. Process improvement principles to adapt physician behavior, the introduction of outcome metrics into the surgical decision-making process, and the development of team-based care can greatly enhance the likelihood of success. AMCs should embrace these challenges to ensure that their residents are well-prepared for the future.

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.

Resident Involvement in Posterior Lumbar Interbody Fusion is Associated With Increased Readmissions and Operative Time, But No Increased Short-term Risks

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The aim was to compare rates of adverse events and additional posterior lumbar interbody fusion (PLIF) cases assisted by residents versus cases performed solely by an orthopedic attending.

SUMMARY OF BACKGROUND DATA

PLIF is a widely accepted surgical technique for the management of a variety of spinal conditions requiring spinal stabilization and fusion. However, no published studies have assessed the effects of resident involvement on intraoperative and postoperative outcomes in PLIF.

METHODS

This retrospective study utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) registry from 2007 to 2012 to identify patients who underwent PLIF procedures. A propensity score matching model was utilized to reduce patient cohort variances. The perioperative data and outcomes in the matched population were analyzed using paired t test and the McNemar test in order to assess, based on resident presence, the rates of postoperative adverse events, readmission, reoperation within 30 days, and operative time.

RESULTS

In total, 1633 patients undergoing PLIF were included in the study, with 24.62% involving resident participation. The propensity score matching algorithm yielded 396 well-matched resident and nonresident pairs. Patients undergoing PLIF involving a resident were associated with a higher rate of readmission (1.77% vs. 0.00%; P=0.008), and longer operative time (245.7 vs. 197.7 min; P<0.001). However, these procedures were not associated with any significant difference in minor or severe adverse events.

CONCLUSIONS

Resident involvement in PLIF was associated with an increased rate of readmissions, and operative time; however, was not associated with an increase in minor or severe adverse events. Further investigation is needed to characterize the role of resident involvement based on level of training experience, as well as methods to improve the learning curve to independence while reducing postoperative hospital length of stay.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

How Does the Presence of a Surgical Trainee Impact Patient Outcomes in Lumbar Fusion Surgery?

BACKGROUND

While the impact of trainee involvement in other surgical fields is well established, there is a paucity of literature assessing this relationship in orthopaedic spine surgery. The goal of this study was to further elucidate this relationship.

METHODS

A retrospective cohort study was initiated on patients undergoing 1-3 level lumbar spine fusion at a single academic center. Operative reports from cases were examined, and patients were divided into 2 groups depending on whether a fellow or resident (F/R) or a physician's assistant (PA) was used as the primary assist. Patients with less than 1-year follow-up were excluded. Multiple linear regression was used to assess change in each patient-reported outcome, and multiple binary logistic regression was used to determine significant predictors of revision, infection, and 30- or 90-day readmission.

RESULTS

One hundred and seventy-two patients were included in the F/R group compared with 178 patients in the PA group. No differences existed between groups for total surgery time, length of stay, 30- or 90-day readmissions, infection, or revision rates. No differences existed between groups in terms of patient-reported outcomes preoperatively or postoperatively. In addition, presence of a surgical trainee was not a significant predictor of patient outcomes or rates of infection, overall revision, or 30- and 90-day readmission rates.

CONCLUSIONS

The results of this study indicate the presence of an orthopaedic spine F/R does not increase complication rates and does not affect short-term patient-reported outcomes in lumbar decompression and fusion surgery.

LEVEL OF EVIDENCE

3.

Patients' perspectives on the extent of resident participation in the operating room for total hip oxr knee arthroplasty

INTRODUCTION

Previous work suggests that patients do not understand the extent of resident involvement in their care and are also uncomfortable with resident involvement.

METHODS

We recruited 202 English speaking patients with previous or planned total joint arthroplasty of the lower limb for a prospective survey trial. We assessed participant's knowledge of resident level of education and confidence of resident involvement in their surgery as a function of supervision.

RESULTS

Participants' mean level of confidence in the consultant surgeon was 4.30 (SD±1.13) on a 5-point Likert scale. Confidence in residents was significantly less, regardless of experience (p < 0.05). 11.1% of participants did not want residents involved in their treatment. 60.6% would like to know more about the education level of the trainee. Less than half of participants correctly identified the education level of residents and fellows.

CONCLUSION

Patient confidence in residents performing part or all of their surgery increases with resident experience and supervision. Compared with attending surgeons, patients have significantly less confidence in residents performing their surgery, including while supervised. Most patients do not understand the educational progression of medical trainees and would like to know more about the education level of the resident involved in their care. Further work should explore how we can help patients better understand resident involvement in their surgical care.

The Impact of Resident Involvement on Surgical Outcomes following Anterior Cruciate Ligament Reconstruction

Hands-on participation in the operating room (OR) is an integral component of surgical resident training. However, the implications of resident involvement in many orthopaedic procedures are not well defined. This study aims to assess the effect of resident involvement on short-term outcomes following anterior cruciate ligament reconstruction (ACLR). The National Surgical Quality Improvement Program (NSQIP) database was queried to identify all patients who underwent ACLR from 2005 to 2012. Demographic variables, resident participation, 30-day complications, and intraoperative time parameters were assessed for all cases. Resident and nonresident cases were matched using propensity scores. Outcomes were analyzed using univariate and multivariate regression analyses, as well as stratified by resident level of training. Univariate analysis of 1,222 resident and 1,188 nonresident cases demonstrated no difference in acute postoperative complication rates between groups. There was no significant difference in the incidence of overall complications based on resident level of training (p = 0.109). Operative time was significantly longer for cases in which a resident was involved (109.5 vs. 101.7 minutes; p < 0.001). Multivariate analysis identified no significant predictors of major postoperative complications, while patient history of chronic obstructive pulmonary disease was the only independent risk factor associated with minor complications. Resident involvement in ACLR was not associated with 30-day complications despite a slight increase in operative time. These findings provide reassurance that resident involvement in ACLR procedures is safe, although future investigations should focus on long-term postoperative outcomes.

A Matched Comparison of Postoperative Complications Between Smokers and Nonsmokers Following Open Reduction Internal Fixation of Distal Radius Fractures

PURPOSE

The purpose of the present study was to identify differences in 30-day adverse events, reoperations, readmissions, and mortality for smokers and nonsmokers who undergo operative treatment for a distal radius fracture.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried for patients who had operatively treated distal radius fractures between 2005 and 2017. Patient characteristics and surgical variables were assessed. Thirty-day outcome data were collected on serious (SAEs) and minor adverse events (MAEs), as well as on infection, return to the operating room, readmission, and mortality. Multivariable logistic analyses with and without propensity-score matching was used to compare outcome measures between the smoker and the nonsmoker cohorts.

RESULTS

In total, 16,158 cases were identified, of whom 3,062 were smokers. After 1:1 propensity-score matching, the smoking and nonsmoking cohorts had similar demographic characteristics. Based on the multivariable propensity-matched logistic regression, cases in the smoking group had a significantly higher rate of any adverse event (AAE) (odds ratio [OR], 1.75; 95% confidence interval [95% CI], 1.28-2.38), serious adverse event (SAE) (OR, 1.75; 95% CI, 1.22-2.50), and minor adverse event (MAE) (OR, 1.84; 95% CI, 1.04-3.23). Smokers also had higher rates of infection (OR, 1.73; 95% CI, 1.26-2.39), reoperation (OR, 2.07; 95% CI, 1.13-3.78), and readmission (OR, 1.83; 95% CI, 1.20-2.79). There was no difference in 30-day mortality rate.

CONCLUSIONS

Smokers who undergo open reduction internal fixation of distal radius fractures had an increased risk of 30-day perioperative adverse events, even with matching and controlling for demographic characteristics and comorbidity status. This information can be used for patient counseling and may be helpful for treatment/management planning.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Are Patient Outcomes Affected by the Presence of a Fellow or Resident in Lumbar Decompression Surgery?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim of this study was to determine whether the presence of a fellow or resident (F/R) compared to a physician assistant (PA) affected surgical variables or short-term patient outcomes.

SUMMARY OF BACKGROUND DATA

Although orthopedic spine fellows and residents must participate in minimum number of decompression surgeries to gain competency, the impact of trainee presence on patient outcomes has not been assessed.

METHODS

One hundred and seventy-one patients that underwent a one- to three-level lumbar spine decompression procedure at a high-volume academic center were retrospectively identified. Operative reports from all cases were examined and patients were placed into one of two groups based on whether the first assist was a F/R or a PA. Univariate analysis was used to compare differences in total surgery duration, 30-day and 90-day readmissions, infection and revision rates, patient-reported outcome measures (Short Form-12 Physical Component Score and Mental Component Score, Oswestry Disability Index, Visual Analog Scale [VAS] Back, VAS Leg) between groups. Multiple linear regression was used to assess change in each patient reported outcome and multiple binary logistic regression was used to determine significant predictors of revision, infection, and 30- or 90-day readmission.

RESULTS

Seventy-eight patients were included in the F/R group compared to 93 patients in the PA group. There were no differences between groups for total surgery time, 30-day or 90-day readmissions, infection, or revision rates. Using univariate analysis, there were no differences between the two groups pre- or postoperatively (P > 0.05). Using multivariate analysis, presence of a surgical trainee did not significantly influence any patient reported outcome and did not affect infection, revision, or 30- and 90-day readmission rates.

CONCLUSION

This is one of the first studies to show that the presence of an orthopedic spine fellow or resident does not affect patient short-term outcomes in lumbar decompression surgery.

LEVEL OF EVIDENCE

3.

Residents' Learning Curve of Total Knee Arthroplasty Based on Radiological Outcome Parameters: A Retrospective Comparative Study

BACKGROUND

This study aimed to plot the impact of a learning curve for a resident's first 103 total knee arthroplasties (TKAs) based on radiological deviations and incision to closure time (ICT), and to compare it to 103 matched TKAs performed by a senior surgeon.

METHODS

This is a retrospective comparative study comprising a total of 206 TKAs and evaluated the results based on radiographic outcome and ICT. Radiological evaluation was performed according to a predefined implemented radiological grading system (RGS). t-Tests compared ICT and RGS; data of mechanical axis were observed with Man-Whitey U-tests and Wilcoxon signed-rank-tests.

RESULTS

The study included 206 patients (mean age 73 years, mean body mass index of 30). Determining all the deviation points (DP) with the RGS, the deviation ratio for resident vs senior surgeon was 0.96:0.5 DP (P = .0002). The learning curve based on DP showed a decrease over time with statistical significance in the first (26 DP, P = .0001), second (21 DP, P = .0059), and fourth (20 DP, P = .0187) quintiles of implanted cases. The ICT of the resident showed a decrease within the quintiles from 79.45 minutes (first quintile) to 65.17 minutes (fifth quintile), for an improvement of 14.28 minutes. When the quintiles are viewed in relation to the mean operation time of the senior surgeon (mean ICT 66.04 minutes), the mean values of the first and the second quintiles remain statistically significant.

CONCLUSION

Supervised TKA showed statistical significance in the learning curves according to deviations documented with a predefined radiological outcome assessment system as well as to ICTs.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Resident Involvement in Arthroscopic Knee Surgery Is Not Associated With Increased Short-term Risk to Patients

Background:

Whether resident involvement in surgical procedures affects intra- and/or postoperative outcomes is controversial.

Purpose/Hypothesis:

The purpose of this study was to compare operative time, adverse events, and readmission rate for arthroscopic knee surgery cases with and without resident involvement. We hypothesized that resident involvement would not negatively affect these variables.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective review of the prospectively maintained National Surgical Quality Improvement Program was performed. Patients who underwent arthroscopic knee surgery between 2005 and 2012 were identified. Multivariate Poisson regression with robust error variance was used to compare the rates of postoperative adverse events and readmission within 30 days between cases with and without resident involvement. Multivariate linear regression was used to compare operative time between cohorts. Because of multiple statistical comparisons, a Bonferroni correction was used, and statistical significance was set at P < .004.

Results:

A total of 29,539 patients who underwent arthroscopic knee surgery were included in the study, and 11.3% of these patients had a resident involved with the case. The overall rate of adverse events was 1.62%. On multivariate analysis, resident involvement was not associated with increased rates of adverse events or readmission. Resident cases had a mean 6-minute increase in operative time (P < .001).

Conclusion:

Overall, resident involvement in arthroscopic knee surgery was not associated with an increased risk of adverse events or readmission. Resident involvement was associated with only a mean increased operative time of 6 minutes, a difference that is not likely to be clinically significant. These results support the safety of resident involvement with arthroscopic knee surgery.

The July Effect for Total Joint Arthroplasty Procedures

The "July effect" refers to the assumed increased risk of complications during the months when medical school graduates transition to residency programs. The actual existence of a July effect is controversial. With this study, the authors sought to determine whether evidence exists for the presence of a July effect among total joint arthroplasty (TJA) procedures. The 2013 and 2014 Nationwide Readmission Databases were combined and all index primary and revision arthroplasty procedures were identified, and then patients from December were excluded. Thirty-day readmission rates, time to readmission, and readmission costs were analyzed by index procedure month and index procedure type. A total of 1,193,034 procedures (index primary: n=1,107,657; revision arthroplasty: n=85,377) were identified. Among all procedure types, 46,674 (3.9%) 30-day readmissions were observed. Among all procedures, an index procedure with a discharge in July resulted in the highest monthly readmission rate of the year (4.2%), which was significantly higher than the mean annual readmission rate (P<.0001). This effect was most pronounced for primary total knee arthroplasty (3.9% vs 3.6%, P<.0001). When stratifying results into teaching vs nonteaching hospitals, the highest readmission rate occurred if the index procedure occurred at a nonteaching hospital in July (4.5%, P<.0001). These data provide evidence that a July effect appears to exist for TJA procedures and is most pronounced at nonteaching institutions. Based on published mean readmission costs, the total annualized cost variation attributable to the higher readmission rate for primary TJA procedures in July is approximately $18.6 million. [Orthopedics. 2020;43(6):e543-e548.].

Operating Room Intervention Rates After Orthopaedic Resident-reduced Pediatric Both-Bone Forearm Fractures Relative to the Academic Calendar

BACKGROUND

The purpose of this study was to evaluate the operating room (OR) intervention rates and quality of fracture reductions for pediatric diaphyseal both-bone forearm fractures performed by orthopaedic residents relative to the academic year. OR intervention was defined as any procedure performed in the OR, including closed reduction and casting, and was used to identify fractures that required secondary intervention after initial closed reduction performed by an orthopaedic resident in the emergency department.

METHODS

A retrospective analysis identified pediatric patients presenting at our institution with both-bone forearm fractures from July 2010 to June 2016. Emergency-room sedation time, highest experience of orthopaedic resident documented to be present at the time of sedation (in postgraduate months), and frequencies of OR intervention were obtained by chart review. Fracture characteristics were determined by radiographic review. Immediate postreduction radiographs were used to measure cast indices, and adequacy of reduction was determined by postreduction angulation and translation.

RESULTS

During the time period studied, 470 both-bone forearm reductions under sedation were performed by an orthopaedic resident at our institution. Of these, 41 fractures (41 patients) required 42 OR interventions (40 involved surgical fixation and 2 were repeat closed reductions). The academic year was divided into quartiles. The April to June quartile had the highest overall percentage of OR intervention (10.6%), followed by July to September (8.6%); however, there was no significant difference between quartiles in the percentages of reductions that needed OR intervention (P=0.553). There was also no correlation between the experience level of the resident performing the reduction (based on postgraduate months) and the frequency of OR intervention (P=0.244). The anteroposterior (AP) and lateral reduction grades did not vary based on quarters (P=0.584; 0.353). The ability to obtain adequate reduction and the rate of unacceptable cast index were also not significantly different between quarters (P=0.347 and 0.465).

CONCLUSIONS

We found no significant difference in rates of OR intervention or the quality of reduction for pediatric both-bone diaphyseal forearm fractures treated by orthopaedic residents relative to the academic year.

LEVEL OF EVIDENCE

Level III-comparative cohort study.

Editorial Commentary: Resident Involvement in Orthopaedic Surgical Procedures Does Not Negatively Impact Patients

Residency and fellowship training programs have evolved significantly over the past 20 years. As the practice of medicine has become more sophisticated, and as increased economic factors exert pressures on health care delivery, postgraduate physician education is naturally affected. Residency programs have always been a formalized, graduate level apprenticeship, and there is really no way to adequately train new physicians other than direct experience in patient care. In surgery, this means providing young trainees the opportunity to be involved in surgical procedures with a gradual increase in autonomy. However, potential negative impacts, which may include financial or legal ramifications for the providers and adverse outcomes for the patient, are real. As a program director and clinician, I personally struggle with these challenges in balancing quality patient care, efficiency, and education.

Overlapping Surgery for Ankle Fractures: Is It Safe?

OBJECTIVE

To determine whether the practice of overlapping surgery influenced patient safety after open reduction internal fixation (ORIF) for ankle fractures.

DESIGN

Retrospective case-control.

SETTING

Level 1 Academic Midwest trauma center.

PATIENTS

All patients who underwent ankle fracture ORIF by a single surgeon were eligible for our study, with 478 total patients.

INTERVENTION

Cases that were overlapping were compared against cases that were not overlapping. Cases were defined as overlapping if there was greater than 30 minutes of overlap between procedural times. Patient complications were recorded up to a year from the index surgery.

MAIN OUTCOME MEASURE

Unexpected return to surgery.

RESULTS

There were 478 ankle fracture ORIF patients, 238 with at least 3 months follow-up; 124 (52%) in the overlapping group and 114 (48%) in the nonoverlapping group. There was no difference in the rate of unexpected return to surgery (P = 0.76), infection (P = 0.52), readmission (P = 0.96), painful implant (P = 0.62), malunion (P = 0.27), nonunion (P = 0.52), or arthritis (P = 0.39) between the overlapping and nonoverlapping groups. There were 467 isolated ankle fractures used for time analysis. Average procedure time was 26 minutes longer for the overlapping group than the nonoverlapping group (P < 0.01).

CONCLUSIONS

Overlapping surgery causes increased operative time for ankle ORIF, but there was no apparent increased risk to the patients for short-term complications. The need for graduated resident responsibility required by ACGME guidelines need to be weighed against the decreased efficiency of operating room time.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Overlapping Surgery Increases Operating Room Efficiency Without Adversely Affecting Outcomes in Total Hip and Knee Arthroplasty

BACKGROUND

Several recent studies have demonstrated that overlapping surgeries in total hip (THA) and knee (TKA) arthroplasty do not increase the rates of complications, but whether this practice is cost-effective has yet to be addressed in the literature. The purpose of this study is to determine the effect of overlapping surgery on procedural costs and surgical productivity during THA and TKA.

METHODS

We identified all patients undergoing primary THA or TKA from 2015 to 2018 by 18 surgeons at a single orthopedic specialty hospital. Procedural and personnel costs were calculated for each case using a time-driven activity-based costing algorithm. Overlap of surgical time by at least 30 minutes was used to define an overlapping procedure. We compared costs and outcomes between overlapping and nonoverlapping procedures, standardizing all costs to 8-hour time blocks. A multivariate regression analysis was performed to determine independent effect of overlapping procedures on costs and outcomes.

RESULTS

Of the 4786 consecutive procedures, 968 (20.2%) overlapped by at least 30 minutes. Although overlapping rooms increased mean operative time by 8.3 minutes (P < .0001) and operating room personnel costs by $80 per case (<.0001), overlapping surgeons could perform significantly more procedures per 8 hours (7.6 vs 6.4; P < .0001), increasing total 8-hour profit margin by $1215 per procedure. There was no difference in 90-day readmission rate, length of stay, or rates of discharge home between the groups.

CONCLUSION

Overlapping noncritical portions of procedures in primary THA and TKA appear to be both a safe practice and an effective strategy.

The Association Between Newly Accredited Orthopedic Residency Programs and Teaching Hospital Complication Rates in Lower Extremity Total Joint Arthroplasty

OBJECTIVE

The influence of residency programs on teaching hospital outcomes in total joint arthroplasty (TJA) has recently been debated. This study investigates how complication and readmission rates for primary elective total hip (THA) and total knee arthroplasty (TKA) changed before and after new orthopedic surgery residency programs meeting ACGME accreditation requirements were introduced at hospitals.

DESIGN

We conducted a retrospective cohort study using the CMS Hospital Compare database, which contains hospital-level data on risk-standardized complication and readmission rates (2013-2018) for primary elective THA and TKA in Medicare beneficiaries. Orthopedic surgery residency programs that were newly accredited during this time were identified using ACGME publicly available data.

SETTING

Eight primary adult teaching hospitals with complication and readmission data in the CMS database available prior to the first full year its affiliated residency program was implemented, and with subsequent program data also available.

PARTICIPANTS

Six ACGME accredited orthopedic surgery residency programs.

RESULTS

Even after controlling for annual variation in surrounding hospital rates, the at-risk patient volume, and variation in starting rates for a given hospital in the first available year, multivariate linear regression demonstrated that complication rates for lower extremity TJA in Medicare beneficiaries decreased by 0.20 per year (R² = 0.78, p = 0.005) after hospitals introduced new orthopedic surgery residency programs meeting ACGME accreditation requirements. There were no significant differences in readmission rates after the addition of newly accredited programs to these same hospitals (R² = 0.51; p = 0.706).

CONCLUSIONS

Starting an orthopedic surgery residency program meeting ACGME accreditation requirements was associated with significantly reduced complication rates for primary elective lower extremity TJA in Medicare beneficiaries at teaching hospitals where these programs began rotating residents. These findings raise awareness regarding the potential for residency programs to contribute to improved patient care outside of the operating room as well as through direct resident involvement in procedures.

Fellow Versus Resident: Graduate Medical Education and Patient Outcomes After Anterior Cervical Diskectomy and Fusion Surgery

INTRODUCTION

The effect of spine fellow versus orthopaedic surgery resident assistance on outcomes in anterior cervical diskectomy and fusion (ACDF) has not been well studied. The objective of this study was to determine differences in patient health-related outcomes based on the level of surgical trainees.

METHODS

Consecutive cases of ACDF (n = 407) were reviewed at a single high-volume institution between 2015 and 2017 and were separated into two groups based on whether they were fellow-assisted or resident-assisted. Demographic and clinical variables were recorded, and health-related quality of life was evaluated using the Short Form-12 (SF-12) survey. The SF-12, visual analog scale pain score, and neck disability index were compared between the two groups. Surgery level, surgical time, preoperative Charlson Comorbidity Index, estimated blood loss, equivalent morphine use, perioperative complications, and 30-day readmission were also recorded. Patient outcomes were compared using an unpaired t-test as well as multivariate linear regression, controlling for age, sex, body mass index, Charlson Comorbidity Index, presurgical visual analog scale, SF-12, and neck disability index. Results were reported with the 95% confidence interval.

RESULTS

Spine surgery fellows and orthopaedic surgery residents participated in 228 and 179 ACDF cases, respectively. No notable demographic differences between the two groups were found. A higher proportion of three or more level ACDF surgeries assisted by fellows versus residents was found. Estimated blood loss was greater in fellow-assisted ACDF cases. Both surgery time and total time in the room were also longer in the fellow-assisted ACDF group. No 30-day readmissions were found in either groups, and only one case of acute hemorrhagic anemia was found in the fellow-assisted group. Overall, postoperative complications were higher in the resident group; however, no difference with regard to intraoperative complications between groups was found.

DISCUSSION

This study shows that patient health-related outcomes are similar in ACDF cases that were fellow-assisted versus resident-assisted. However, fellow-assisted ACDF cases were associated with more blood loss and longer surgery time.

Does a "July Effect" Exist for Fellowship Training in Total Hip and Knee Arthroplasty?

BACKGROUND

The hypothetical association between health-care errors and the transition of the medical academic year has been termed the "July effect." Data supporting its existence are conflicting, particularly in orthopedic surgery, and prior studies have inappropriately grouped fellows with resident trainees. No studies to date have examined whether a training initiation effect exists among surgical fellows in adult reconstructive orthopedics.

METHODS

This is a level IV retrospective cohort study reviewing 15,650 primary hip and knee arthroplasties performed from 2006 to 2016 at a single institution. Forty arthroplasty fellows were trained during this 10-year period. Primary outcome measures included intraoperative complications, additional procedures, revisions, and nonoperative complications within 90 days of surgery. These complication rates were analyzed by quarter of academic year and by temporal progression through three-month fellowship rotations.

RESULTS

There were no differences in intraoperative complication, revision, or nonoperative complication rates between any academic quarter. There was a single statistically lower rate of additional procedures in the third quarter (1.2%) than in the fourth quarter (1.8%, P = .04). The most common complication in this subset was wound dehiscence for patients undergoing hip arthroplasty and stiffness for patients undergoing knee arthroplasty. There was no difference in complication rates during the first, second, or third month as fellows progressed through a single rotation.

CONCLUSION

This study does not support the existence of a training-initiation effect among fellows in adult hip and knee reconstruction. Graduated autonomy can be safely employed in a fellowship program without negatively impacting patient outcomes, ensuring the continued high-caliber training of future surgeons.

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.

Impact of resident involvement on cervical and lumbar spine surgery outcomes

BACKGROUND CONTEXT

Resident involvement in the operating room is a vital component of their medical education. Conflicting and limited research exists regarding the effects of surgical resident participation on spine surgery patient outcomes.

PURPOSE

To determine the effect of resident involvement on surgery duration, length of hospital stay and 30-day postoperative complication rates in common spinal surgery using the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database.

STUDY DESIGN

Multicenter retrospective cohort study.

PATIENT SAMPLE

A total of 1,441 patients met the inclusion criteria: 1,142 patients had surgeries with an attending physician alone and 299 patients had surgeries with trainee involvement. All anterior cervical or posterior lumbar surgery patients were identified. Patients who had missing trainee involvement information, surgery for cancer, preoperative infection or dirty wound classification, spine fractures, traumatic spinal cord injury, intradural surgery, thoracic surgery, and emergency surgery were excluded.

OUTCOME MEASURES

The main outcomes of interest analyzed from the ACS-NSQIP database included surgical complications, medical complications, length of hospital stay, and surgery duration.

METHODS

Propensity score for risk of any complication was calculated to account for baseline characteristic differences between the attending alone and trainee present group. Multivariate logistic regression was used to investigate the impact of resident involvement on surgery duration, length of hospital stay, and 30-day postoperative complication rates.

RESULTS

After adjusting using the calculated propensity score, the multivariate analysis demonstrated that there was no significant difference in any complication rates between surgeries involving trainees compared to surgeries with attending surgeons alone. Surgery times were found to be significantly longer for surgeries involving trainees. To further explore this relationship, separate analyses were performed for tertiles of predicted surgery duration, cervical or lumbar surgery, fusion or nonfusion, and inpatient or outpatient surgery. The effect of trainee involvement on increasing surgery time remained significant for medium predicted surgery duration, longer predicted surgery duration, cervical surgery, lumbar surgery, fusion surgery, and inpatient surgery. There were no significant differences reported for any other factors.

CONCLUSIONS

After adjusting for confounding, we demonstrated in a national database that resident involvement in surgeries did not increase complication rates. We demonstrated that surgeries with more complex features may lead to an increase in operative time when trainees are involved. Further study is required to determine how to efficiently integrate resident involvement in surgeries without affecting their medical education.

The presence of residents during orthopedic operation exerts no negative influence on outcome

BACKGROUND

Operative procedural training is a key component of orthopedic surgery residency. It is unclear how and whether residents participation in orthopedic surgical procedures impacts on post-operative outcomes.

SOURCES OF DATA

A systematic search was performed to identify articles in which the presence of a resident in the operating room was certified, and was compared with interventions without the presence of residents.

AREAS OF AGREEMENT

There is a likely beneficial role of residents in the operating room, and there is only a weak association between the presence of a resident and a worse outcome for orthopedic surgical patients.

AREAS OF CONTROVERSY

Most of the studies were undertaken in USA, and this represents a limit from the point of view of comparison with other academic and clinical realities.

GROWING POINT

The data provide support for continued and perhaps increased involvement of resident in orthopedic surgery.

AREAS OF RESEARCH

To clarify the role of residents on clinically relevant outcomes in orthopedic patients, appropriately powered randomized control trials should be planned.

The Effect of the Level of Training of the First Assistant on the Outcomes of Adolescent Idiopathic Scoliosis Surgery

BACKGROUND

At academic medical centers, residents and fellows play an integral role as surgical first assistants in spinal deformity surgery. However, limited data exist on whether the experience level of the surgical assistant affects outcomes.

METHODS

We conducted a multicenter, multisurgeon study comparing perioperative and postoperative outcomes after adolescent idiopathic scoliosis (AIS) surgery for the same 11 surgeons who performed cases that were assisted by residents compared with cases that were assisted by fellows. Blood loss, operative time, duration of hospitalization, complication rates, Scoliosis Research Society (SRS)-22 questionnaire scores, and radiographic outcomes were compared between the 2 groups.

RESULTS

We evaluated outcomes for 347 surgical procedures; 118 cases were assisted by residents and 229 were assisted by fellows. Preoperative radiographic and demographic parameters were not different between the groups. The resident group had significantly more estimated blood loss than the fellow group (939 compared with 762 mL, p = 0.02). Otherwise, the perioperative characteristics were similar between the groups, including the volume of the autologous blood recovery system product that was transfused, the operative time, and the occurrence of intraoperative neuromonitoring changes. Postoperatively, the percentage correction of the Cobb angle, the number of levels that had been fused, the number of days until the discharge criteria had been met, and the rate of major complications were similar between the groups. At the 2-year follow-up, the overall and subdomain SRS-22 questionnaire scores were not different between the groups, except that patients in the resident-assisted group had slightly worse pain scores than those in the fellow-assisted group (4.3 compared with 4.5, p = 0.01).

CONCLUSIONS

The first assistant's level of training did not affect clinical or radiographic outcomes following AIS surgery.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.