Effect of surgeon fatigue on hip and knee arthroplasty.

In an effort to reduce wait times associated with joint replacement surgery, the overall arthroplasty caseload in the province in Ontario has increased by more than 50% in the past 5 years.1,2 As a result, the number of total joint arthroplasties being performed during a surgical day has also increased. Many surgeons now perform 5 or 6 total joint operations in a single day, with operative working hours approaching 10. There is no doubt that this increased caseload has led to increased surgeon fatigue, particularly for cases performed at the end of the operating day compared with those performed at the beginning. There is growing support in the literature that patient outcomes are adversely affected by fatigue in operator-dependent cognitive and technical tasks. Adverse events and medical errors have been shown to occur more frequently in sleep-deprived physicians, and technical skills have also been shown to be negatively influenced by physician fatigue.3–9 More specifically, laparoscopic procedures,10 cardiac interventions,11 endotracheal intubation12 and colonoscopies13,14 have been shown to have inferior outcomes when performed later in the day. These findings potentially have implications for physician productivity, procedural outcome and, most importantly, patient safety. There are many factors that contribute to the outcome of total joint arthroplasty, including preoperative, intraoperative and postoperative variables. It is well established that preoperative variables, such as unrealistic patient expectations,15–18 diabetic control19,20 and obesity,21–23 can have a negative effect on radiologic and functional outcomes. Fortunately, these variables are modifiable and therefore have the potential to be optimized preoperatively. Postoperative variables, such as participation in rehabilitation and avoidance of limb positions that may predispose to hip dislocation, are also modifiable variables that have been shown to affect outcome.24,25 The influence of intraoperative variables on outcomes in total joint arthroplasty have been less extensively studied. Duration of the surgical procedure,26,27 blood loss28 and component alignment29–33 are modifiable intraoperative variables that influence patient outcomes and may be adversely affected by surgeon fatigue. To our knowledge, the extent to which fatigue affects the technical and cognitive skills of the surgeon and overall patient outcomes in total joint arthroplasty has not previously been studied. The purpose of this retrospective study was to determine whether there is a difference, in terms of perioperative and postoperative complications, between patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) at different times during the operative day.