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Is After-Hours Orthopaedic Surgery Associated with Adverse Outcomes?

A Prospective Comparative Study

Ricci, William M., MD1; Gallagher, Bethany, MD1; Brandt, Angel, MA1; Schwappach, John, MD2; Tucker, Michael, MD3; Leighton, Ross, MD4

doi: 10.2106/JBJS.H.00661
Scientific Articles

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:

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

Copyright © 2009 by The Journal of Bone and Joint Surgery, Incorporated
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