Background: Treatment of fractures is sometimes performed after normal daytime operating hours and in such instances may be performed under less than ideal conditions. The consequence of performing operations under such conditions is largely unknown and was therefore studied in the context of intramedullary nail fixation of tibial and femoral shaft fractures.
Methods: Two hundred and three consecutive patients with either a femoral or tibial shaft fracture (Orthopaedic Trauma Association classification 32 or 42) treated with intramedullary nail fixation were included in a prospective, multicenter, nonrandomized study. Patients were divided into an after-hours group defined as an operation beginning from 4:00 P.M. to 6:00 A.M. or a daytime group defined as an operation beginning from 6:00 A.M. to 4:00 P.M. These groups were further divided on the basis of the injured bone into the following subgroups: after-hours femoral fracture (fifty-five patients), daytime femoral fracture (forty-four patients), after-hours tibial fracture (forty-eight patients), and daytime tibial fracture (fifty-six patients). The demographic and fracture characteristics were similar among the subgroups. All patients were treated with the same type of femoral antegrade, femoral retrograde, or tibial nail fixation with reaming. Data for fracture-healing, complications, operative time, and fluoroscopy time were collected prospectively.
Results: The healing rates were similar between daytime and after-hours surgery groups for both the tibial and femoral nailing. On the basis of univariate analysis, operative times were shorter in the after-hours group compared with the daytime group for both the tibial and femoral nail fixation groups (p < 0.02), but regression analysis failed to identify time of surgery as an independent variable associated with operative time. Radiation exposure was similar for the after-hours group and the daytime group for both tibial and femoral nail fixation (p > 0.05). The after-hours group had more unplanned reoperations than the daytime group (p < 0.02). Removal of painful hardware was more frequent in the after-hours femoral fracture group (27%) than in the daytime femoral fracture group (3%) (p < 0.02), and after-hours surgery was an independent variable associated with the need for removal of painful femoral fracture hardware (p < 0.05).
Conclusions: Rates of nonunion, infectious complications, and radiation exposure are similar for after-hours and daytime surgery for intramedullary nail fixation of both femoral and tibial fractures. After-hours femoral nail fixation was associated with an increased frequency for removal of painful hardware, which may be related to technical errors associated with nonideal conditions and shorter operative times. An increase in the allocated amount of daytime operative time for orthopaedic trauma surgery has the potential to reduce minor complication rates for intramedullary nail fixation.
Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.
1Washington University School of Medicine at Barnes-Jewish Hospital, One Barnes-Jewish Hospital Plaza, Suite 11300, St. Louis, MO 63110. E-mail address for W.M. Ricci: firstname.lastname@example.org
2Colorado Orthopaedic Consultants PC, 1411 South Potomac Street, Suite 400, Denver, CO 80012
3Palmetto Health Richland, 3 Richland Medical Park Drive, Suite 330, Columbia, SC 29203
4Halifax Infirmary, Room 4875, Halifax, NS B3H 3A7, Canada
The optimal timing of operative treatment of fractures is dependent on a multitude of factors. Many fractures do not require urgent or emergent care and therefore can be scheduled with discretion. However, patients with fractures that meet indications for emergent treatment often require an operation without regard for the condition of the operative team. Between these extremes are patients who require urgent, but neither discretionary nor emergent, scheduling of their operative fracture care. The scarcity of daytime resources allocated for such traumatized patients often requires that fracture fixation procedures be performed after normal daytime operating hours.
Multiple studies have attempted to generate a consensus for determining the acuity of musculoskeletal injuries that require emergent treatment1-5. One strategy to reduce after-hours operating is to narrow the subset of conditions that are considered truly emergent. A second strategy is to provide sufficient daytime operating capacity to minimize the need to operate after hours for nonemergent conditions. A marked decrease in after-hours operating has been shown to occur when a dedicated trauma operating room was made available daily6. Whether reducing after-hours operations benefits patients and/or surgeons is not clear. Most orthopaedic surgeons who take call often have normal patient-care responsibilities the day after call, even if they are sleep-deprived because of operating after hours. Such fatigue has been shown in nonorthopaedic disciplines to impair surgical performance and potentially lead to an increase in surgical errors and even a substantially higher mortality rate7-10.
Any potentially negative effect on operative outcomes of orthopaedic surgery performed after hours remains largely unknown. The goal of this investigation was to quantify the effect of operations performed after hours by comparing intramedullary nail fixation of femoral and tibial shaft fractures performed in normal daytime operating hours with the same procedures performed after hours with respect to operative time, radiation exposure, and complications such as delayed union or nonunion, infection, and reoperation rate.
Materials and Methods
Two hundred and thirteen consecutive patients with acute femoral or tibial shaft fractures treated with intramedullary nail fixation over a three-year period, from January 2001 to December 2003, were included in this prospective, multicenter, nonrandomized study approved by the institutional review board. The sample size was one of convenience. All four centers were Level-I trauma centers, and all but one were residency training programs. At all centers, an attending orthopaedic traumatologist was present for each operation, regardless of the time of day. Ten patients without accurate data for the time of day of their operative procedure were excluded from all analyses. The remaining 203 patients were initially divided into two groups: the daytime group included 100 patients treated during daytime hours, defined as being between 6:00 A.M. and 4:00 P.M., and the after-hours group included 103 patients treated after hours, defined as being between 4:00 P.M. and 6:00 A.M. These groups were also subdivided into those with a femoral fracture (fifty-five patients were in the after-hours femoral fracture subgroup and forty-four, in the daytime femoral fracture subgroup) and those with a tibial fracture (forty-eight patients were in the after-hours tibial fracture subgroup and fifty-six, in the daytime tibial fracture subgroup). The timing of surgery was based solely on the attending surgeon's normal practice habits. The demographic characteristics of the groups were similar (p > 0.05) and are presented in Table I.
On the basis of the inclusion criteria, all patients had a fracture of either the femoral (Orthopaedic Trauma Association [OTA] classification 32) or tibial (OTA 42) shaft11. The distribution of fracture type and injury mechanisms between the after-hours and daytime groups was similar for both the femoral and tibial subgroups (Tables II and III). Open fractures were graded according to the system of Gustilo and Anderson12. The distribution of open and closed femoral fractures in the after-hours and daytime subgroups was similar (p > 0.05) (Table IV). Among the tibial fracture subgroups, the increase in the rate of open fractures in the patients treated after hours (38%) compared with those treated during the daytime (25%) was not significant (p > 0.05) (Table IV).
All patients were treated with reamed nail fixation (TriGen intramedullary nail system; Smith and Nephew, Memphis, Tennessee). Patients with a femoral fracture were treated with either an antegrade (sixty-four patients) or a retrograde (thirty-five) nailing technique.
Perioperative data, including operative time (from skin incision to skin closure), fluoroscopic time (measured directly from the c-arm imaging unit), and postoperative fracture alignment were collected prospectively for all patients. Operative time was defined as the time for the nailing procedure. The time required for the treatment of other injuries and the time for associated débridement procedures were not included in this measurement. Patients were followed prospectively with clinical and radiographic evaluations at four, six, and twelve months. Seventy patients with a femoral fracture and eighty-two with a tibial fracture were followed at least to healing or establishment of a nonunion. Fifty-one patients (25%) were lost to follow-up and were excluded from the analysis of postoperative complications but were included in the analysis of intraoperative data. The remaining patients were followed for an average of twelve months (range, six to thirty months). Complications, including nonunion, delayed union, malalignment, infections, and reoperation, were recorded prospectively. Union was defined as painless weight-bearing with bridging callus seen on orthogonal radiographs. Delayed union was defined as failure of union over four months, and nonunion was defined as a lack of progressive fracture-healing over three consecutive months. Malalignment was defined as >5° of angular deformity, >10° of rotational deformity, or >1 cm of axial displacement. Infection was defined as the requirement for either intravenous antibiotics or surgical débridement. The reason for all reoperations was recorded, with removal of painful hardware distinguished from removal of hardware for other reasons such as nonunion repair.
Significance was defined by p < 0.05. Dichotomous variables, including fracture type, mechanism, open or closed fracture, occurrences of delayed union or nonunion, and reoperation, were compared with use of the chi-square test. Continuous variables, including operative time and fluoroscopy time, were compared with use of a two-tailed t test. Logistic regression analysis utilized operative time, fluoroscopy time, and treatment time (daytime hours or after hours) as dependent variables and Orthopaedic Trauma Association fracture classification, open or closed fracture, and the complication of removal of painful hardware as independent variables. A post hoc power analysis was performed on the radiation exposure data.
Source of Funding
This study was funded by Smith and Nephew (Memphis, Tennessee).
The average operative time was shorter for surgery in the after-hours group for both the femoral and tibial fracture subgroups. The average operative time (and standard deviation) for the after-hours femoral fracture group (56.5 ± 21.2 minutes) was 19% less than that for the daytime femoral fracture group (70.0 ± 35.3 minutes) (p < 0.02). The average operative time for the after-hours tibial fracture group (55.1 ± 33.6 minutes) was 23% less than that for the daytime tibial fracture group (71.6 ± 29.9 minutes) (p < 0.01). Logistic regression analysis for both the femoral and tibial fracture groups revealed that after-hours surgery was not an independent variable for operative time (p > 0.05).
Post hoc analysis indicated that the study is underpowered to make statistical comparisons of radiation exposure between groups. Over 900 patients would be required in each group to achieve a power of 80%. The average fluoroscopy time for the after-hours femoral fracture group was thirteen seconds less (100.4 ± 74.4 seconds) than that for the daytime femoral fracture group (113.0 ± 122.1 seconds). The average fluoroscopy time for the after-hours tibial fracture group (72.4 ± 86.0 seconds) was 10.2 seconds less than that for the daytime tibial fracture group (82.6 ± 57.8 seconds).
Among the 152 patients who were followed to healing or the establishment of a delayed union or nonunion, the after-hours group had a twofold higher likelihood of undergoing an unplanned reoperation (twenty-eight [34%] of eighty-two patients) than the daytime group (twelve [17%] of seventy patients) (p < 0.02). Reoperation for removal of painful hardware was much more frequent in the after-hours subgroups. Eleven (27%) of the forty-one patients in the after-hours femoral fracture group and one (3%) of the twenty-nine patients in the daytime femoral fracture group required removal of painful hardware (p < 0.02). With the numbers studied, no difference was detected between the after-hours tibial fracture and daytime tibial fracture subgroups (p > 0.1) with regard to the need for removal of painful hardware (Table V). No difference was found in the healing complication rate between the after-hours and daytime groups (p > 0.9). Delayed union or nonunion occurred in three patients (7%; one was an open fracture) in the after-hours femoral fracture group, two (7%; both were closed fractures) in the daytime femoral fracture group, five (12%; four were open fractures) in the after-hours tibial fracture group, and five (12%; two were open fractures) in the daytime tibial fracture group. Logistic regression analysis for the femoral group revealed that after-hours surgery was an independent variable for the removal of painful hardware (p < 0.05).
Treatment of patients with fractures often requires that surgery take place after normal daytime operating hours. There are many potential reasons for operating after hours. In some instances, the condition of the patient or the fracture characteristics require emergent operative intervention regardless of the time of day. In other instances, the reason for operating after hours is dictated by a lack of daytime resources. Surgery performed after hours has the potential to be under less than ideal conditions. Since it is not customary for surgeons to work shifts, surgeons operating after hours are usually doing so after having already completed a full daytime work schedule. When these procedures are performed during normal sleeping hours, the potential for surgeon fatigue is magnified. Fatigue of the surgeon could lead to adverse events. Other potentially detrimental aspects of after-hours surgery are the increased likelihood of having a surgical team (scrub nurse, circulating nurse, fluoroscopy technician, and/or anesthesia provider) who is unfamiliar with the procedure. The determination of whether operating after hours, under such potentially less than ideal circumstances, is associated with an increase in adverse outcomes was unquantified prior to this investigation.
The effect of surgical timing on complications after fracture treatment has been studied1-3. The context of these investigations has been to determine differences between outcomes of immediate treatment compared with delayed treatment, but without regard to the time of day. We studied patients treated for a femoral or tibial shaft fracture with intramedullary nail fixation and compared those treated after hours with those treated during normal daytime hours. Surgery initiated before 6:00 A.M. or after 4:00 P.M. is often associated with “off shift” nursing personnel. Therefore, for the purposes of this study, procedures starting between 6:00 A.M. and 4:00 P.M. were considered to have been performed during daytime hours, and surgery beginning after 4:00 P.M. and before 6:00 A.M. was considered to have been performed after hours. The timing of the surgical procedures was based on the surgeon's normal practices and was not dictated by this study in any way.
It was interesting to note that the demographic and fracture characteristics were similar for those treated during daytime hours and those treated after hours. We expected there to be more open fractures in the after-hours group since this is the most common indication for emergent surgery in the population studied. This was the trend for the tibial group, with 38% of those treated after hours and 25% of those treated during daytime hours having open fractures; however, with the numbers studied, this difference did not reach significance. Among the patients treated for femoral shaft fractures, the distributions of closed and open fractures between those treated after hours and those treated during daytime hours were similar (Table IV).
Healing complications are outcomes that are the least likely to be attributable to any adverse conditions associated with after-hours surgery. The severity of the fracture, the severity of the associated soft-tissue injury, and the comorbid conditions are factors that are likely to contribute most to healing and are independent of surgical time of day. Indeed, our results indicate no association between after-hours surgery and such healing complications. Conversely, outcomes that are more directly related to surgical technique have a greater potential to be affected by adverse operating conditions. The prominence of interlocking screws and the prominence of the driving end of the nail are factors that are directly related to surgical technique and have little or no relation to fracture, soft-tissue, or patient-related factors. The increased need for reoperation for painful implants seen in the patients treated after hours indicates an association of this complication with the timing of the surgical procedure. This finding may also be related to the decreased surgical times seen in the after-hours groups. Whether this reduced surgical time is due to increased haste on the part of the surgeon or to other factors remains unknown. This finding is consistent with the results reported by Bhattacharyya et al., who reviewed complications of operations performed at night6. Both fixation of intertrochanteric hip fractures and intramedullary nail fixation of femoral fractures were evaluated. Only three complications occurred in the intertrochanteric fracture group, but each followed an after-hours index procedure. Review of their femoral nail fixation group also showed a significant increase in complications from after-hours surgery. The four complications recorded included two related to prominent hardware, one malrotation, and one associated femoral neck fracture that had been missed.
There are inherent limitations to the present study. There were no predefined criteria for after-hours surgery. The relative conditions for operating after hours compared with those for operating during daytime hours could not be controlled. It is possible that the surgical teams for after-hours operations were equivalent to or superior to the teams staffing the daytime operations.
In conclusion, the conditions associated with after-hours orthopaedic trauma surgery, particularly femoral nail fixation, appear to contribute to an increased prevalence of technical complications leading to reoperation for the removal of painful implants. Increased surgeon attention to these technical details and increased resources for daytime orthopaedic trauma surgery have the potential to reduce such complications and the frequency of associated reoperations.
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from Smith and Nephew. In addition, one or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Smith and Nephew). Also, a commercial entity (Smith and Nephew) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors, or a member of his or her immediate family, is affiliated or associated.
A video supplement to this article will be available from the Video Journal of Orthopaedics. A video clip will be available at the JBJS web site, www.jbjs.org. The Video Journal of Orthopaedics can be contacted at (805) 962-3410, web site: www.vjortho.com.
Investigation performed at Washington University School of Medicine, St. Louis, Missouri; Swedish Medical Center, Englewood, Colorado; Medical College of Georgia, Augusta, Georgia; and Halifax Infirmary, Halifax, Nova Scotia, Canada
1. Gupta N, Kay RM, Leitch K, Femino JD, Tolo VT, Skaggs DL. Effect of surgical delay on perioperative complications and need for open reduction in supracondylar humerus fractures in children. J Pediatr Orthop. 2004;24:245-8.
2. Lindvall E, Haidukewych G, DiPasquale T, Herscovici D Jr, Sanders R. Open reduction and stable fixation of isolated, displaced talar neck and body fractures. J Bone Joint Surg Am. 2004;86:2229-34.
3. Mehlman CT, Strub WM, Roy DR, Wall EJ, Crawford AH. The effect of surgical timing on the perioperative complications of treatment of supracondylar humeral fractures in children. J Bone Joint Surg Am. 2001;83:323-7.
4. McKee M, Priest P, Ginzler M, Black N. What is the requirement for out-of-hours operating in orthopaedics? Arch Emerg Med. 1993;10:91-9.
5. Yeatman M, Cameron-Smith A, Moore JM. Nocturnal orthopaedic operating: can we let sleeping orthopaedic surgeons lie? Ann R Coll Surg Engl. 1994;76:90-4.
6. Bhattacharyya T, Vrahas MS, Morrison SM, Kim E, Wiklund RA, Smith RM, Rubash HE. The value of the dedicated orthopaedic trauma operating room. J Trauma. 2006;60:1336-41.
7. Taffinder NJ, McManus IC, Gul Y, Russell RC, Darzi A. Effect of sleep deprivation on surgeons' dexterity on laparoscopy simulator. Lancet. 1998;352:1191.
8. Gawande AA, Zinner MJ, Studdert DM, Brennan TA. Analysis of errors reported by surgeons at three teaching hospitals. Surgery. 2003;133:614-21.
9. Saleem MA, Kannam H, Aronow WS, Weiss MB, Kalapatapu K, Pucillo AL, Monsen CE. The effects of off-normal hours, age, and gender for coronary angioplasty on hospital mortality in patients undergoing coronary angioplasty for acute myocardial infarction. Am J Cardiol. 2004;93:763-4.
10. Henriques JP, Haasdijk AP, Zijlstra F; Zwolle Myocardial Infarction Study Group. Outcome of primary angioplasty for acute myocardial infarction during routine duty hours versus during off-hours. J Am Coll Cardiol. 2003;41:2138-42.
11. Fracture and dislocation compendium. Orthopaedic Trauma Association Committee for Coding and Classification. J Orthop Trauma. 1996;10 Suppl 1:v-ix, 1-154.
12. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58:453-8.