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Operative Time as an Independent and Modifiable Risk Factor for Short-Term Complications After Knee Arthroscopy

      Purpose

      To determine whether operative time is an independent risk factor for 30-day complications after arthroscopic surgical procedures on the knee.

      Methods

      The American College of Surgeons National Surgical Quality Improvement Program database was queried between 2005 and 2016 for all arthroscopic knee procedures including lateral release, loose body removal, synovectomy, chondroplasty, microfracture, and meniscectomy. Cases with concomitant procedures were excluded. Correlations between operative time and adverse events were controlled for variables such as age, sex, body mass index, patient comorbidities, and procedure using a multivariate Poisson regression with robust error variance.

      Results

      A total of 78,864 procedures met our inclusion and exclusion criteria. The mean age of patients was 51.0 ± 14.3 years; mean operative time, 31.2 ± 18.1 minutes; and mean body mass index, 31.0 ± 7.8. Arthroscopic lateral release (coefficient, 5.8; 95% confidence interval [CI], 4.8-6.8; P < .001), removal of loose bodies (coefficient, 4.2; 95% CI, 3.2-5.3; P < .001), synovectomy (coefficient, 1.8; 95% CI, 1.2-2.3; P < .001), and microfracture (coefficient, 6.5; 95% CI, 5.8-7.2; P < .001) had significantly greater durations of surgery in comparison with meniscectomy. The overall rate of adverse events was 1.24%. After we adjusted for demographic characteristics and the procedure, a 15-minute increase in operative duration was associated with an increased risk of transfusion (relative risk [RR], 1.5; 95% CI, 1.3-1.8; P < .001), death (RR, 1.6; 95% CI, 1.2-2.1; P = .005), dehiscence (RR, 1.6; 95% CI, 1.2-2.2; P = .002), surgical-site infection (RR, 1.3; 95% CI, 1.2-1.3; P = .001), sepsis (RR, 1.3; 95% CI, 1.2-1.4; P < .001), readmission (RR, 1.1; 95% CI, 1.1-1.2; P < .001), and extended length of stay (RR, 1.4; 95% CI, 1.3-1.4; P < .001).

      Conclusions

      Marginal increases in operative time are associated with an increased risk of adverse events such as surgical-site infection, sepsis, extended length of stay, and readmission. Efforts should be made to maximize surgical efficiency.

      Level of Evidence

      Level IV, retrospective database study.
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      References

        • Kim S.
        • Bosque J.
        • Meehan J.P.
        • Jamali A.
        • Marder R.
        Increase in outpatient knee arthroscopy in the United States: A comparison of National Surveys of Ambulatory Surgery, 1996 and 2006.
        J Bone Joint Surg Am. 2011; 93: 994-1000
        • Dorr L.D.
        • Thomas D.J.
        • Zhu J.
        • Dastane M.
        • Chao L.
        • Long W.T.
        Outpatient total hip arthroplasty.
        J Arthroplasty. 2010; 25: 501-506
        • McNair P.D.
        • Luft H.S.
        Enhancing Medicare's hospital-acquired conditions policy to encompass readmissions.
        Medicare Medicaid Res Rev. 2012; 2 (mmrr.002.02.a03)
        • Cancienne J.M.
        • Brockmeier S.F.
        • Gulotta L.V.
        • Dines D.M.
        • Werner B.C.
        Ambulatory total shoulder arthroplasty: A comprehensive analysis of current trends, complications, readmissions, and costs.
        J Bone Joint Surg Am. 2017; 99: 629-637
        • Greenwald A.S.
        • Bassano A.
        • Wiggins S.
        • Froimson M.I.
        Alternative reimbursement models: Bundled payment and beyond: AOA critical issues.
        J Bone Joint Surg Am. 2016; 98: e45
        • Goldfarb C.A.
        • Bansal A.
        • Brophy R.H.
        Ambulatory surgical centers: A review of complications and adverse events.
        J Am Acad Orthop Surg. 2017; 25: 12-22
        • Bohl D.D.
        • Ondeck N.
        • Darrith B.
        • Hannon C.P.
        • Fillingham Y.A.
        • Della Valle C.J.
        Impact of operative time on adverse events following primary total joint arthroplasty.
        J Arthroplasty. 2018; 33: 2256-2262.e4
        • Catanzarite T.
        • Saha S.
        • Pilecki M.A.
        • Kim J.Y.S.
        • Milad M.P.
        Longer operative time during benign laparoscopic and robotic hysterectomy is associated with increased 30-day perioperative complications.
        J Minim Invasive Gynecol. 2015; 22: 1049-1058
        • Vandendriessche D.
        • Giraudet G.
        • Lucot J.-P.
        • Behal H.
        • Cosson M.
        Impact of laparoscopic sacrocolpopexy learning curve on operative time, perioperative complications and short term results.
        Eur J Obstet Gynecol Reprod Biol. 2015; 191: 84-89
        • Peersman G.
        • Laskin R.
        • Davis J.
        • Peterson M.G.E.
        • Richart T.
        Prolonged operative time correlates with increased infection rate after total knee arthroplasty.
        HSS J. 2006; 2: 70-72
        • Boddapati V.
        • Fu M.C.
        • Schairer W.W.
        • et al.
        Increased shoulder arthroscopy time is associated with overnight hospital stay and surgical site infection.
        Arthroscopy. 2018; 34: 363-368
        • Daley B.J.
        • Cecil W.
        • Clarke P.C.
        • Cofer J.B.
        • Guillamondegui O.D.
        How slow is too slow? Correlation of operative time to complications: An analysis from the Tennessee Surgical Quality Collaborative.
        J Am Coll Surg. 2015; 220: 550-558
        • Campbell D.A.J.
        • Henderson W.G.
        • Englesbe M.J.
        • et al.
        Surgical site infection prevention: The importance of operative duration and blood transfusion—Results of the first American College of Surgeons-National Surgical Quality Improvement Program best practices initiative.
        J Am Coll Surg. 2008; 207: 810-820
        • Molina C.S.
        • Thakore R.V.
        • Blumer A.
        • Obremskey W.T.
        • Sethi M.K.
        Use of the National Surgical Quality Improvement Program in orthopaedic surgery.
        Clin Orthop Relat Res. 2015; 473: 1574-1581
        • Basques B.A.
        • Gardner E.C.
        • Varthi A.G.
        • et al.
        Risk factors for short-term adverse events and readmission after arthroscopic meniscectomy: Does age matter?.
        Am J Sports Med. 2015; 43: 169-175
        • Ashraf A.
        • Luo T.D.
        • Christophersen C.
        • Hunter L.R.
        • Dahm D.L.
        • McIntosh A.L.
        Acute and subacute complications of pediatric and adolescent knee arthroscopy.
        Arthroscopy. 2014; 30: 710-714
        • Salzler M.J.
        • Lin A.
        • Miller C.D.
        • Herold S.
        • Irrgang J.J.
        • Harner C.D.
        Complications after arthroscopic knee surgery.
        Am J Sports Med. 2014; 42: 292-296
        • Carr II, J.B.
        • Cancienne J.M.
        • Werner B.C.
        Obstructive sleep apnea affects complication rates following knee arthroscopy but use of continuous positive airway pressure is not protective against complications.
        Knee Surg Sports Traumatol Arthrosc. 2019; 27: 534-540
        • Davis C.L.
        • Pierce J.R.
        • Henderson W.
        • et al.
        Assessment of the reliability of data collected for the Department of Veterans Affairs national surgical quality improvement program.
        J Am Coll Surg. 2007; 204: 550-560
        • Trickey A.W.
        • Wright J.M.
        • Donovan J.
        • et al.
        Interrater reliability of hospital readmission evaluations for surgical patients.
        Am J Med Qual. 2017; 32: 201-207
        • Ondeck N.T.
        • Bohl D.D.
        • McLynn R.P.
        • et al.
        Longer operative time is associated with increased adverse events after anterior cervical diskectomy and fusion: 15-minute intervals matter.
        Orthopedics. 2018; 41: e483-e488
        • Zou G.
        A modified Poisson regression approach to prospective studies with binary data.
        Am J Epidemiol. 2004; 159: 702-706
        • Owen R.M.
        • Perez S.D.
        • Lytle N.
        • et al.
        Impact of operative duration on postoperative pulmonary complications in laparoscopic versus open colectomy.
        Surg Endosc. 2013; 27: 3555-3563
        • Evans C.
        • Lim J.
        • Gatzen C.
        • Huang A.
        Factors influencing laparoscopic colorectal operative duration and its effect on clinical outcome.
        Surg Laparosc Endosc Percutan Tech. 2012; 22: 437-442
        • Jeon B.G.
        • Kim H.J.
        • Jung K.H.
        • et al.
        Prolonged operative time in laparoscopic appendectomy: Predictive factors and outcomes.
        Int J Surg. 2016; 36: 225-232
        • Hetsroni I.
        • Lyman S.
        • Do H.
        • Mann G.
        • Marx R.G.
        Symptomatic pulmonary embolism after outpatient arthroscopic procedures of the knee: The incidence and risk factors in 418,323 arthroscopies.
        J Bone Joint Surg Br. 2011; 93: 47-51
        • Struijk-Mulder M.C.
        • Ettema H.B.
        • Verheyen C.C.P.M.
        • Buller H.R.
        Deep vein thrombosis after arthroscopic anterior cruciate ligament reconstruction: A prospective cohort study of 100 patients.
        Arthroscopy. 2013; 29: 1211-1216
        • Hirota K.
        • Hashimoto H.
        • Tsubo T.
        • Ishihara H.
        • Matsuki A.
        Quantification and comparison of pulmonary emboli formation after pneumatic tourniquet release in patients undergoing reconstruction of anterior cruciate ligament and total knee arthroplasty.
        Anesth Analg. 2002; 94 (table of contents): 1633-1638
        • Fish D.N.
        Is thromboprophylaxis after knee arthroscopy warranted? Commentary on an article by Gregory B. Maletis, MD, et al.: “Incidence of symptomatic venous thromboembolism after elective knee arthroscopy.”.
        J Bone Joint Surg Am. 2012; 94: e54
        • Dong J.
        • Wang X.
        • Men X.
        • Wang X.
        • Zheng X.
        • Gao S.
        Incidence of deep venous thrombosis in Chinese patients undergoing arthroscopic knee surgery for cruciate ligament reconstruction.
        Knee Surg Sports Traumatol Arthrosc. 2015; 23: 3540-3544
        • Mathis M.R.
        • Naughton N.N.
        • Shanks A.M.
        • et al.
        Patient selection for day case-eligible surgery: Identifying those at high risk for major complications.
        Anesthesiology. 2013; 119: 1310-1321
        • Kocher M.S.
        • Logan C.A.
        • Kramer D.E.
        Discoid lateral meniscus in children: Diagnosis, management, and outcomes.
        J Am Acad Orthop Surg. 2017; 25: 736-743
        • Mitchell J.M.
        Effect of physician ownership of specialty hospitals and ambulatory surgery centers on frequency of use of outpatient orthopedic surgery.
        Arch Surg. 2010; 145: 732-738
        • Rao A.J.
        • Bohl D.D.
        • Frank R.M.
        • Cvetanovich G.L.
        • Nicholson G.P.
        • Romeo A.A.
        The “July effect” in total shoulder arthroplasty.
        J Shoulder Elbow Surg. 2017; 26: e59-e64
        • Hoashi J.S.
        • Samdani A.F.
        • Betz R.R.
        • Bastrom T.P.
        • Cahill P.J.
        Is there a “July effect” in surgery for adolescent idiopathic scoliosis?.
        J Bone Joint Surg Am. 2014; 96: e55
        • Lee N.J.
        • Kothari P.
        • Kim C.
        • et al.
        The impact of resident involvement in elective posterior cervical fusion.
        Spine (Phila Pa 1976). 2018; 43: 316-323
        • Bagsby D.T.
        • Loder R.T.
        • Myung K.
        Operative intervention of supracondylar humerus fractures more complicated in July: Analysis of the July effect.
        J Pediatr Orthop. 2017; 37: 254-257
        • Frank R.M.
        • Wang K.C.
        • Davey A.
        • et al.
        Utility of modern arthroscopic simulator training models: A meta-analysis and updated systematic review.
        Arthroscopy. 2018; 34: 1650-1677
        • Henn III, R.F.
        • Shah N.
        • Warner J.J.P.
        • Gomoll A.H.
        Shoulder arthroscopy simulator training improves shoulder arthroscopy performance in a cadaveric model.
        Arthroscopy. 2013; 29: 982-985
        • Waterman B.R.
        • Martin K.D.
        • Cameron K.L.
        • Owens B.D.
        • Belmont P.J.J.
        Simulation training improves surgical proficiency and safety during diagnostic shoulder arthroscopy performed by residents.
        Orthopedics. 2016; 39: e479-e485
        • Akhtar K.
        • Sugand K.
        • Wijendra A.
        • et al.
        The transferability of generic minimally invasive surgical skills: Is there crossover of core skills between laparoscopy and arthroscopy?.
        J Surg Educ. 2016; 73: 329-338
        • Salata M.J.
        • Gibbs A.E.
        • Sekiya J.K.
        A systematic review of clinical outcomes in patients undergoing meniscectomy.
        Am J Sports Med. 2010; 38: 1907-1916

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