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Defining the Key Parts of a Procedure: Implications for Overlapping Surgery

Bernstein, Joseph MD; Bernstein, James J.; Mehta, Samir MD; Hume, Eric L. MD; Schenker, Mara L. MD; Ahn, Jaimo MD, PhD

JAAOS - Journal of the American Academy of Orthopaedic Surgeons: February 15, 2018 - Volume 26 - Issue 4 - p 142-147
doi: 10.5435/JAAOS-D-17-00381
Research Article

Introduction: The American College of Surgeons’ Statements on Principles requires attending surgeons to be present for the “key parts” of surgical procedures, but the term is not defined. The research question addressed in this study is whether a functional definition of the critical or key steps of common orthopaedic surgical procedures can be reliably constructed. We used the examples of hip and knee arthroplasty because these procedures are highly structured and divisible into distinct subroutines.

Methods: We surveyed 100 experienced orthopaedic surgeons regarding whether particular steps in knee and hip arthroplasty procedures were considered “key.” The patterns of individual surgeons’ responses were compared among surgeons for overall reliability. The steps frequently cited as key were also identified.

Results: The agreement rates among surgeons for the definitions of the key parts of hip and knee arthroplasty were 3.2% and 8.6%, respectively. For both procedures, five steps were identified as key by >90% of the respondents.

Discussion: The agreement rate on what constitutes the key parts of hip and knee arthroplasty was poor, despite the fact that these are highly structured procedures. Accordingly, defining the key parts for a given procedure must rely on either the operating surgeon’s discretion or a consensus definition. Imposing a single surgeon’s standard on others is not the optimal approach because such a standard is likely to be idiosyncratic.

Conclusion: A consensus standard articulated by the orthopaedic surgery community may be the best means for identifying the key parts of orthopaedic surgical operations. The data presented here suggest a foundation upon which a consensus definition for the key parts of arthroplasty procedures may be built.

From the Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA (Dr. Joseph Bernstein, Dr. Mehta, Dr. Hume, and Dr. Ahn), Columbia College, Columbia University, New York, NY (Mr. James J. Bernstein), and the Department of Orthopaedic Surgery, Emory University, Atlanta, GA (Dr. Schenker).

Correspondence to Dr. Joseph Bernstein: Joseph.Bernstein@uphs.upenn.edu

Dr. Joseph Bernstein or an immediate family member serves as a board member, owner, officer, or committee member of the American Orthopaedic Association. Dr. Mehta or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of AO North America, Smith & Nephew, and Zimmer Biomet; serves as a paid consultant to Smith & Nephew and DePuy Synthes; has received research or institutional support from Amgen, Medtronic, and Smith & Nephew; and serves as a board member, owner, officer, or committee member of the Pennsylvania Orthopaedic Society. Dr. Hume or an immediate family member serves as a paid consultant to Zimmer Biomet. Dr. Schenker or an immediate family member serves as a paid consultant to Carmell Therapeutics and Miami Device Solutions. Dr. Ahn or an immediate family member serves as a paid consultant to Merck and DePuy Synthes; has stock or stock options held in Skelegen; and serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons, the American Board of Orthopaedic Surgery, the American Orthopaedic Association, the American Physician Scientists Association, the Foundation for Orthopaedic Trauma, the Orthopaedic Research Society, and the Orthopaedic Trauma Association. Neither Mr. J. J. Bernstein nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article.

Copyright 2018 by the American Academy of Orthopaedic Surgeons.
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