Studying the Impact of Overlapping Surgeries on THA and TKA

    A game-changing paper presented at the 2018 AAOS Annual Meeting adds to the evidence on the issue of patient outcomes with overlapping versus consecutive surgeries. Dr. William Hamilton comments on the findings.

    Here’s a question that’s gotten a lot of attention in the past few years: Does running overlapping surgeries in 2 operating rooms jeopardize patient safety?

    At the heart of this question is an article published in the Boston Globe in October 2015 suggesting that it does. [1] The newspaper’s Spotlight Team detailed the case of a 41-year-old male patient who suffered a serious neurologic injury after undergoing cervical corpectomy for ossification of the posterior longitudinal ligament. In a lawsuit against the surgeon and hospital, the patient alleged that his injury resulted from the surgeon leaving his procedure to start another case in another operating room, which he said he was not aware would occur when he agreed to surgery. Ultimately, the jury found that the overlapping surgeries did not factor into the injury.

    The article, however, generated subsequent reports in the media about the perceived dangers of overlapping surgeries and hearings about the practice in Congress. [2] It also prompted healthcare institutions to rethink – and in some cases revise – their guidelines on the practice of overlapping surgeries.

    Despite the claims in the Boston Globe article, studies across the surgical literature generally show no untoward effects of overlapping surgeries. [3-6] A recent study of total hip arthroplasty patients, however, suggests that complications may be more common in patients whose surgeons participate in overlapping surgeries than in those whose surgeons perform consecutive procedures. [7]

    A paper from the Anderson Orthopaedic Clinic in northern Virginia, presented at the 2018 Annual Meeting of the American Academy of Orthopaedic Surgeons in New Orleans, adds to the evidence on the topic of overlapping surgeries. The study was named one of the game-changing research papers presented at the Academy meeting.

    Outcomes were evaluated for nearly 17,000 patients who had undergone total hip arthroplasty (n=7508) or total knee arthroplasty (n=9406) between 2006 and 2016 at a single institution. Surgeons in the Anderson Orthopaedic Clinic practice do both overlapping and consecutive surgeries, giving them a good perspective on the pluses and minuses of the 2 approaches and plenty of data on patient outcomes.

    For the study, they compared component revisions, re-operations, and non-surgical complications between the 2 groups during the 90-day period after surgery. More surgeries were overlapping than consecutive (59% vs 41%, respectively). Similar to other investigators, they found that overlapping surgeries did not compromise patient safety compared with consecutive surgeries, with no differences between groups in:

    • 90-day component revision rates: 0.66% for the consecutive group versus 0.85% for the overlapping group (P=0.17)
    • 90-day complication rates: 1.33% for the consecutive group versus 1.45% for the overlapping group (P=0.50)

    One of the practice surgeons, William G Hamilton, MD, said his preference is “to run overlapping rooms to achieve efficiency on a given OR day. It allows us to do more cases in a shorter amount of time, better utilizing the surgeons’ time and improving access to care for patients.”

    He acknowledged that overlapping surgeries is currently a topic of significant interest, which is most likely why the paper was selected as a “game changer” by the Academy.

    “While the results of the study are not surprising, there is significant need for data to address the topic of running 2 rooms,” Dr. Hamilton said. “Surgeons and policymakers alike are in need of as much data as possible to make informed decisions regarding this topic.”


    Hamilton WG, Ho H, Parks NL, McDonald JF, Hopper R, Goyal N, Fricka KB, Engh CA. Running Two Rooms Does Not Compromise Outcomes or Patient Safety in Total Joint Arthroplasty (Paper 618-GC). Presented at the 2018 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 6-10, 2018, New Orleans, Louisiana.


    The study authors have no disclosures relevant to this paper.


    1. Abelson J, Saltzman J, Kowalczyk L Allen S. Clash in the name of care. Boston Globe. October 25, 2015.
    2. Guan J, Karsy M, Brock AA, Couldwell WT, Schmidt RH. Overlapping surgery: a review of the controversy, the evidence, and future directions. Neurosurgery. 2017 Sep 1;64(CN_suppl_1):110-113. doi: 10.1093/neuros/nyx200.
    3. Yount K, Gillen J, Kron I, et al. Attendings’ performing simultaneous operations in academic cardiothoracic surgery does not increase operative duration or negative affect patient outcomes. Paper presented at American Association for Thoracic Surgery annual meeting, May 14-18, 2016, Baltimore, Maryland.
    4. Zhang AL, Sing DC, Dang DY, et al. Overlapping Surgery in the Ambulatory Orthopaedic Setting. J Bone Joint Surg Am. 2016 Nov 16;98(22):1859-1867.
    5. Guan J, Brock AA, Karsy M, et al. Managing overlapping surgery: an analysis of 1018 neurosurgical and spine cases. J Neurosurg. 2017 Nov;127(5):1096-1104. doi: 10.3171/2016.8.JNS161226. Epub 2016 Dec 2.
    6. Hyder JA, Hanson KT, Storlie CB. Safety of Overlapping Surgery at a High-volume Referral Center. Ann Surg. 2017 Apr;265(4):639-644. doi: 10.1097/SLA.0000000000002084.
    7. Ravi B, Pincus D, Wasserstein D. Association of overlapping surgery with increased risk for complications following hip surgery: a population-based, matched cohort study. JAMA Intern Med. 2018 Jan 1;178(1):75-83. doi: 10.1001/jamainternmed.2017.6835.