The Impact of Resident Involvement on Patient Outcomes in Revision Total Hip Arthroplasty

Alexander, Bradley; Sowers, Mackenzie; Jacob, Roshan; McGwin, Gerald; Maffulli, Nicola; Naranje, Sameer

doi:10.1055/s-0041-1736469

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Original Article • Rev. bras. ortop. 58 (1) • Jan-Feb 2023 • https://doi.org/10.1055/s-0041-1736469 copy

The Impact of Resident Involvement on Patient Outcomes in Revision Total Hip Arthroplasty

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

The aim of the present study was to determine the influence of resident involvement on acute complication rates in revision total hip arthroplasty (THA).

Methods

Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, 1,743 revision THAs were identified from 2008 to 2012; 949 of them involved a resident physician. Demographic information including gender and race, comorbidities including lung disease, heart disease and diabetes, operative time, length of stay, and acute postoperative complications within 30 days were analyzed.

Results

Resident involvement was not associated with a significant increase in the risk of acute complications. Total operative time demonstrated a statistically significant association with the involvement of a resident (161.35 minutes with resident present, 135.07 minutes without resident; p< 0.001). There was no evidence that resident involvement was associated with a longer hospital stay (5.61 days with resident present, 5.22 days without resident; p= 0.46).

Conclusion

Involvement of an orthopedic resident during revision THA does not appear to increase short-term postoperative complication rates, despite a significant increase in operative times.

Keywords
internship and residency; arthroplasty, replacement, hip; orthopedic procedures; postoperative complications

	Resident present, %	Resident not present, %	p-value
Gender
Female	54.12	52.33	0.46
Male	45.88	47.67	0.46
ASA Classification
ASA 1	1.48	1.89	0.51
ASA 2	43.20	39.80
ASA 3	50.47	53.53
ASA 4	4.74	4.79
ASA 5	0.11	0
Race
American Indian or Alaska Native	0.65	0.41	0.78
Asian	1.04	0.55
Black or African American	6.61	6.05
Native Hawaiian or Pacific Islander	0.13	0.14
White	91.58	92.85
Anesthesia
Epidural	0.21	1.01	< 0.001
General	74.71	73.17
Conscious/Intravenous sedation	0.53	0
Monitored anesthesia care	0.11	0.13
Regional	8.96	1.89
Spinal	15.28	23.80
Unknown	0.21	0
Chronic obstructive pulmonary disease	4.64	6.93	0.04
Congestive heart failure within 30 days before surgery	0.74	0.88	0.79
History of myocardial infarction 6 months prior to surgery	0.53	0.26	0.46
History of angina in 1 month before surgery	0.63	0.39	0.52
Acute renal failure, post-operatively	0.11	0.25	0.59
Previous percutaneous coronary intervention	7.17	7.47	0.85
EtOH > 2 drinks/day in 2 weeks before admission	4.11	3.22	0.37
Previous cardiac surgery	6.32	6.57	0.84
History of revascularization/amputation for peripheral vascular disease	0.53	1.29	0.11
Currently on dialysis, pre-operatively	0.32	0.63	0.48
History of transient ischemic attacks	3.37	3.48	0.89
Cerebrovascular accident/stroke with neurological deficit	2.32	2.19	> 0.99
Cerebrovascular accident/stroke with no neurological deficit	3.07	3.22	0.89
Paraplegia	0.32	0.26	> 0.99
Hemiplegia	0.95	0.64	0.59
Quadriplegia	0.21	0	0.50
Chemotherapy for malignancy in ≤ 30 days before revision total hip arthroplasty	0.53	0.39	0.73
Disseminated cancer	0.42	1.01	0.15
Steroid use for chronic condition	6.22	4.53	0.13
> 10% loss body weight in last 6 months	0.63	1.26	0.21
Bleeding disorders	5.90	6.05	0.91
Prior operation within 30 days	3.79	6.52	0.01
Hypertension requiring medication	55.53	63.98	< 0.001
Current smoker within 1 year	15.38	14.74	0.73
Diabetes Status
Diabetes mellitus with insulin	3.37	3.78	0.005
Diabetes mellitus without oral agents or insulin	87.46	87.15
Diabetes mellitus with non-oral and non-insulin agents	6.95	4.41
Diabetes mellitus with oral agents	2.21	4.66
Functional health status prior to surgery
Independent	85.46	84.13	0.08
Partially dependent	13.49	13.22
Totally dependent	1.05	2.52
Unknown	0	0.13
Inpatient	98.10	99.37	0.02

	Resident present (n= 949)	Resident not present (n= 794)	p-value
Operative time, minutes	161.35	135.07	< 0.001
Length of stay, days	5.61	5.22	0.46
Acute postoperative complications, n (%)
Graft/Prosthesis/Flap Failure	5 (0.53)	4 (0.50)	> 0.99
Superficial infection	9 (0.95)	11 (1.39)	0.49
Deep infection	12 (1.26)	16 (2.02)	0.25
Wound dehiscence	4 (0.42)	5 (0.63)	0.73
Reoperation	61 (6.43)	58 (7.30)	0.50
Pneumonia	4 (0.42)	6 (0.76)	0.52
Unplanned intubation	6 (0.63)	7 (0.88)	0.58
Deep vein thrombosis	7 (0.74)	7 (0.88)	0.79
Pulmonary embolism	1 (0.11)	1 (0.13)	> 0.99
Ventilation > 48 hours	4 (0.42)	5 (0.63)	0 0.73
Renal insufficiency	3 (0.32)	2 (0.25)	> 0.99
Acute renal failure	2 (0.21)	2 (0.25)	> 0.99
Urinary tract infection	19 (2.00)	16 (2.02)	> 0.99
Stroke/Cerebrovascular Accident	2 (0.21)	4 (0.50)	0.42
Peripheral nerve injury	6 (0.63)	4 (0.50)	0.76
Cardiac arrest	3 (0.32)	4 (0.50)	0.70
Myocardial infarction	9 (0.95)	5 (0.63)	0.59

Covariates	Change in operative time, minutes	p-value
Gender - Female	- 11.13	< 0.001
ASA Classification 1	- 23.96	0.03
ASA Classification 2	- 9.44	0.001
Race - Black or African American	10.79	0.02
Anesthesia - Regional	- 38.47	< 0.001
Anesthesia - Spinal	- 19.947	< 0.001
Previous percutaneous coronary intervention - Yes	- 10.093	0.03
Prior operation within 30 days - Yes	- 23.460	< 0.001
Current smoker within 1 year - Yes	- 9.958	0.01
Outpatient	- 40.224	< 0.001
Resident present	28.412	< 0.001

Sociedade Brasileira de Ortopedia e Traumatologia Al. Lorena, 427 14º andar, 01424-000 São Paulo - SP - Brasil, Tel.: 55 11 2137-5400 - São Paulo - SP - Brazil
E-mail: rbo@sbot.org.br

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[1] Address for correspondence Sameer Naranje, MD, Division of Orthopaedic Surgery, University of Alabama at Birmingham, 1201 11th Ave S #200, Birmingham, AL 35205, United States (e-mail: snaranje@uabmc.edu).