Orthopaedic residents' autonomy in hip fracture surgery: what is the effect on patient outcomes?

Abstract

Background: In the context of growing prevalence of hip fractures and hip fracture surgery in the elderly, it is unknown if surgical trainee autonomy in the operating room conflicts with optimal health care provision and safety of patients. We hypothesized that surgery performed solely by residents, without supervision or participation of an attending surgeon, can provide similar outcomes to surgery performed by trauma or joint reconstruction fellowship-trained orthopaedic surgeons.

Methods: A single-center cohort was retrospectively reviewed for all hip fracture cases, surgically treated with hemiarthroplasty or internal fixation during 2016. Data were analyzed and compared between surgery performed solely by post-graduate-year 4 to 6 residents, and surgery performed by trauma or joint replacement fellowship-trained surgeons. Demographics, time to surgery, and American Society of Anesthesiologists Physical Status Classification System (ASA), surgical parameters, preoperative and postoperative radiographs as well as primary (mortality, complications and revision surgery) and secondary outcome variables were collected and analyzed. Univariate analysis and Kaplan-Meier survival analysis were performed to evaluate outcomes.

Results: Out of 478 cases, 404 (84.5%) were included in this study. Non-operative cases, techniques used solely by attending surgeons, such as total hip replacement, were excluded. The average follow-up time was 26.1 months (SD 10.9). Analysis of internal fixation and hemiarthroplasty groups demonstrated no significant difference between residents and attendings in complications (p = 0.353, 0.850, respectively), and mortality (p = 0.796, 0.734, respectively). In both groups, surgery time was significantly longer in the resident group (p < 0.001).

Conclusion: The current study demonstrates that hip fracture surgery performed by adequately trained orthopaedic surgery residents can provide similar results to surgery performed by fellowship-trained attendings.

Level of evidence: Level III-retrospective cohort study.

Keywords: Autonomy; Competency; Complications; Hip fracture surgery; Hip fractures; Mortality; Resident training.