Impact of surgical case order on peri-operative outcomes for total joint arthroplasty

  • Li Xiang 
  • Zhang Qi 
  • Dong Jiyuan 
  • Zhang Guoqiang 
  • Chai Wei 
  • Chen Jiying 
Original Paper



There is growing support in the literatures that peri-operative outcomes are adversely affected by surgical case order in some certain surgical procedures. This study aimed to examine if similar phenomenon is also shared in total joint arthroplasty (TJA).


A total of 6548 joints (5183 patients) treated with primary TJA by a total of five surgeons at our institution from December 2011 to December 2015 were retrospectively reviewed in this study. Demographic data, operative duration, blood loss, peri-operative adverse events, medical cost, and length of hospital stay were collected and analyzed. Logistic regression was used to determine risk factors for adverse events.


Of the 6548 cases in this cohort, 1643 TJAs were classified as first round cases, 1744 TJAs were second round cases, 1600 TJAs were third round cases, and 1561 TJAs were fourth or later round cases. Mean operating time was shorter in the intermediate cases (45.0 vs. 41.0 vs. 41.8 vs. 54.1 min, P < 0.01). Peri-operative arthroplastic adverse events were increased in later surgical cases (2.07% vs. 2.18% vs. 3.06% vs. 4.87%, P < 0.01). Later case order (OR = 1.40 [95% CI: 1.22–1.61], P < 0.01) was a significant risk factor of arthroplastic adverse events. Patients undergoing TJA later in the day were more likely to have longer length of stay and higher cost than earlier cases. Peri-operative systemic complications and blood loss did not significantly differ between groups.


Surgical case order is an independent risk factor for arthroplastic adverse events in TJA. TJA procedures performed later in the day have a higher risk for arthroplastic adverse events, but not for systematic adverse events. Significantly increased operative time, higher cost, and longer LOS were noted for fourth or later TJA cases. Data in our study reveals that performing more than three TJAs within a single day may imply compromised outcomes.


Total joint arthroplasty Surgical case order Surgeon fatigue Complication 



We thank the patients who enrolled in this study and the staff involved in this work.


This study was funded by Beijing Natural Science Foundation (7174384).

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.


  1. 1.
    Kane RL, Saleh KJ, Wilt TJ, Bershadsky B (2005) The functional outcomes of total knee arthroplasty. J Bone Joint Surg Am 87(8):1719–1724. PubMedGoogle Scholar
  2. 2.
    Carr AJ, Robertsson O, Graves S, Price AJ, Arden NK, Judge A, Beard DJ (2012) Knee replacement. Lancet 379(9823):1331–1340. CrossRefPubMedGoogle Scholar
  3. 3.
    Pivec R, Johnson AJ, Mears SC, Mont MA (2012) Hip arthroplasty. Lancet 380(9855):1768–1777. CrossRefPubMedGoogle Scholar
  4. 4.
    Skou ST, Roos EM, Laursen MB, Rathleff MS, Arendt-Nielsen L, Simonsen O, Rasmussen S (2015) A randomized, controlled trial of Total knee replacement. N Engl J Med 373(17):1597–1606. CrossRefPubMedGoogle Scholar
  5. 5.
    Kurtz S, Mowat F, Ong K, Chan N, Lau E, Halpern M (2005) Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. J Bone Joint Surg Am 87(7):1487–1497. PubMedGoogle Scholar
  6. 6.
    Kurtz S, Ong K, Lau E, Mowat F, Halpern M (2007) Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 89(4):780–785. PubMedGoogle Scholar
  7. 7.
    Singh JA, Vessely MB, Harmsen WS, Schleck CD, Melton LJ 3rd, Kurland RL, Berry DJ (2010) A population-based study of trends in the use of total hip and total knee arthroplasty, 1969-2008. Mayo Clin Proc 85(10):898–904. CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Kelz RR, Freeman KM, Hosokawa PW, Asch DA, Spitz FR, Moskowitz M, Henderson WG, Mitchell ME, Itani KM (2008) Time of day is associated with postoperative morbidity: an analysis of the national surgical quality improvement program data. Ann Surg 247(3):544–552. CrossRefPubMedGoogle Scholar
  9. 9.
    Thomas AA, Kim B, Derboghossians A, Chang A, Finley DS, Chien GW, Slezak J, Jacobsen SJ (2014) Impact of surgical case order on perioperative outcomes for robotic-assisted radical prostatectomy. Urol Ann 6(2):142–146. CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Gupta D, Taravati P (2015) Effect of surgical case order on cataract surgery complication rates and procedure time. J Cataract Refract Surg 41(3):594–597. CrossRefPubMedGoogle Scholar
  11. 11.
    Govindarajan A, Urbach DR, Kumar M, Li Q, Murray BJ, Juurlink D, Kennedy E, Gagliardi A, Sutradhar R, Baxter NN (2015) Outcomes of daytime procedures performed by attending surgeons after night work. N Engl J Med 373(9):845–853. CrossRefPubMedGoogle Scholar
  12. 12.
    Kahol K, Leyba MJ, Deka M, Deka V, Mayes S, Smith M, Ferrara JJ, Panchanathan S (2008) Effect of fatigue on psychomotor and cognitive skills. Am J Surg 195(2):195–204. CrossRefPubMedGoogle Scholar
  13. 13.
    Peskun C, Walmsley D, Waddell J, Schemitsch E (2012) Effect of surgeon fatigue on hip and knee arthroplasty. Can J Surg 55(2):81–86. CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Nadler SB, Hidalgo JH, Bloch T (1962) Prediction of blood volume in normal human adults. Surgery 51(2):224–232PubMedGoogle Scholar
  15. 15.
    Sehat KR, Evans R, Newman JH (2000) How much blood is really lost in total knee arthroplasty?. Correct blood loss management should take hidden loss into account. Knee 7(3):151–155CrossRefPubMedGoogle Scholar
  16. 16.
    Administration FaD (2014) What is a serious adverse event?.
  17. 17.
    Basques BA, Toy JO, Bohl DD, Golinvaux NS, Grauer JN (2015) General compared with spinal anesthesia for total hip arthroplasty. J Bone Joint Surg Am 97(6):455–461. CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Nwachukwu BU, Dy CJ, Burket JC, Padgett DE, Lyman S (2015) Risk for complication after Total joint arthroplasty at a Center of Excellence: the impact of patient travel distance. J Arthroplast 30(6):1058–1061. CrossRefGoogle Scholar
  19. 19.
    Kahol K, Satava RM, Ferrara J, Smith ML (2009) Effect of short-term pretrial practice on surgical proficiency in simulated environments: a randomized trial of the "preoperative warm-up" effect. J Am Coll Surg 208(2):255–268. CrossRefPubMedGoogle Scholar
  20. 20.
    Willis-Owen CA, Konyves A, Martin DK (2010) Factors affecting the incidence of infection in hip and knee replacement: an analysis of 5277 cases. J Bone Joint Surg Br 92(8):1128–1133. CrossRefPubMedGoogle Scholar
  21. 21.
    Kapadia BH, Berg RA, Daley JA, Fritz J, Bhave A, Mont MA (2016) Periprosthetic joint infection. Lancet 387(10016):386–394. CrossRefPubMedGoogle Scholar
  22. 22.
    Chen AF, Kheir MM, Greenbaum JM, Restrepo C, Maltenfort MG, Parvizi J (2017) Surgical case order has an effect on the risk of subsequent Periprosthetic joint infection. J Arthroplast 32(7):2234–2238. CrossRefGoogle Scholar
  23. 23.
    Gorenoi V, Schonermark MP, Hagen A (2009) Arthroplasty register for Germany. GMS Health Technol Assess 5:Doc13. PubMedPubMedCentralGoogle Scholar
  24. 24.
    Hunt LP, Ben-Shlomo Y, Clark EM, Dieppe P, Judge A, MacGregor AJ, Tobias JH, Vernon K, Blom AW, National Joint Registry for E, Wales (2014) 45-day mortality after 467,779 knee replacements for osteoarthritis from the National Joint Registry for England and Wales: an observational study. Lancet 384(9952):1429–1436. CrossRefPubMedGoogle Scholar
  25. 25.
    Hunt LP, Ben-Shlomo Y, Clark EM, Dieppe P, Judge A, MacGregor AJ, Tobias JH, Vernon K, Blom AW, National Joint Registry for England W, Northern I (2013) 90-day mortality after 409,096 total hip replacements for osteoarthritis, from the National Joint Registry for England and Wales: a retrospective analysis. Lancet 382(9898):1097–1104. CrossRefPubMedGoogle Scholar
  26. 26.
    National Joint Registry for England WaNI (2014) The National Joint Registry Annual Report 2014Google Scholar
  27. 27.
    University L (2015) Swedish Knee Arthroplasty Register Annual report 2015Google Scholar
  28. 28.
    Bagrodia A, Rachakonda V, Delafuente K, Toombs S, Yeh O, Scales J, Roehrborn CG, Lotan Y (2012) Surgeon fatigue: impact of case order on perioperative parameters and patient outcomes. J Urol 188(4):1291–1296. CrossRefPubMedGoogle Scholar
  29. 29.
    Schieman C, MacLean AR, Buie WD, Rudmik LR, Ghali WA, Dixon E (2008) Does surgeon fatigue influence outcomes after anterior resection for rectal cancer? Am J Surg 195(5):684–687; discussion 687-688. CrossRefPubMedGoogle Scholar
  30. 30.
    Sturm L, Dawson D, Vaughan R, Hewett P, Hill AG, Graham JC, Maddern GJ (2011) Effects of fatigue on surgeon performance and surgical outcomes: a systematic review. ANZ J Surg 81(7–8):502–509CrossRefPubMedGoogle Scholar
  31. 31.
    Beredjiklian JGPK (2007) Core knowledge in Orthopaedics: adult reconstruction and arthroplasty. Mosby, PhiladelphiaGoogle Scholar
  32. 32.
    Kim YH, Kwon OR, Kim JS (2009) Is one-stage bilateral sequential total hip replacement as safe as unilateral total hip replacement? J Bone Joint Surg Br 91(3):316–320. CrossRefPubMedGoogle Scholar
  33. 33.
    Stavrakis AI, SooHoo NF, Lieberman JR (2015) Bilateral Total hip arthroplasty has similar complication rates to unilateral Total hip arthroplasty. J Arthroplast 30(7):1211–1214. CrossRefGoogle Scholar

Copyright information

© SICOT aisbl 2018

Authors and Affiliations

  • Li Xiang 
    • 1
  • Zhang Qi 
    • 2
  • Dong Jiyuan 
    • 1
  • Zhang Guoqiang 
    • 1
  • Chai Wei 
    • 1
  • Chen Jiying 
    • 1
  1. 1.Department of Orthopedics, Chinese PLA General Hospital and Medical School of Chinese PLABeijingChina
  2. 2.Department of OrthopedicsBeijing Jishuitan Hospital and Peking University Fourth School of Clinical MedicineBeijingChina

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