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The Journal of Arthroplasty Vol. 27 No. 6 2012

Do Previous Operative Reports Provide theCritical Information Necessary for Revision Total

Hip Arthroplasty?

Nitin Goyal, MD,* Claudio Diaz-Ledezma, MD,y Mohan Tripathi, BA,zMatthew S. Austin, MD,y§ and Javad Parvizi, MDy§

Abstract: An operative note is a vital component of a patient's medical-legal record, permittingthe surgical team to safely administer perioperative care. Despite this critical function, operativenote contents are neither standardized nor regulated; this is especially concerning in orthopedicsurgery. As younger patients undergo total hip arthroplasty (THA) and outlive their prostheses, theneed for revision THA cannot be ignored. Surgeons performing primary THA must be cognizant torecord detailed implant characteristics to ensure that if necessary, the revision surgeon will have allpertinent information to optimally treat the patient. Our survey of operative notes reveals thedismal nature of component documentation during primary THA; implementation of a standard-ized procedure-specific operative note guideline may minimize incomplete dictations and drivesurgeons to include all pertinent information. Keywords: revision hip arthroplasty, operativenote, documentation, component, adult reconstruction.© 2012 Elsevier Inc. All rights reserved.

An operative note is the official documentation of asurgical procedure and functions to record details of thesurgery, documents key findings, and contains vital in-formation essential for effective and safe patient care.These records may be implemented for research andaudit purposes but are also a part of a patient's medical-legal record. The Joint Commission on Accreditationof Healthcare Organizations requires an operative dic-tation or procedure note for any invasive procedure by aphysician [1]. Despite these critical functions, thecontents of operative notes are neither standardizednor regulated. This is especially concerning in ortho-paedic surgery. Because of extensive use of implantsduring orthopedic surgery, particularly total jointarthroplasty, the operative note not only functions todocument key anatomical structures encountered andpathologic findings but also should function to metic-

e *Anderson Orthopaedic Clinic, Alexandria, Virginia; yThenstitute, Philadelphia, Pennsylvania; zJefferson Medical College,a, Pennsylvania; and §Thomas Jefferson University Hospital,a, Pennsylvania.ted August 19, 2011; accepted January 29, 2012.nflict of Interest statement associated with this article can beoi:10.1016/j.arth.2012.01.028.requests: Nitin Goyal, MD, Anderson Orthopaedic Clinic,y Navy Drive, Alexandria, VA.Elsevier Inc. All rights reserved.

403/2706-0032$36.00/0016/j.arth.2012.01.028

102

ulously document the exact type of component usedand its dimensions for both patient safety, accuraterecord-keeping purposes, and as a reference if futuresurgery is required.Total hip arthroplasty (THA) continues to be one of the

most successful and commonly performed surgicalprocedures in the United States and around the world[2,3]. Despite advances in surgical technique and com-ponent manufacturing, the possibility of requiringrevision surgery remains a concern for both the patientand surgeon. Between 1991 and 2005, a 53.1% increasein the number of primary THAs performed was docu-mented; during the same period, the number of revisionTHAs increased by 26.9% [4].It is clear that a sound knowledge of the components

used during primary THA affords the reconstructivesurgeon a more solid foundation upon which to pre-operatively map the revision procedure and understandall available options. Knowledge of components isespecially important, given the ever-expanding arma-mentarium of hip components available to the surgeonperforming the primary surgery. Since the advent ofthe Moore prosthesis in 1952, the incidence of hiparthroplasty has increased tremendously and the mul-titude of medical device manufacturers have developedliterally hundreds of hip prostheses, each with its owncomponent dimensions and characteristics. Just in thepast 10 years, the United States Food and Drug Ad-ministration has approved 15 novel hip prostheses [5].

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1024 The Journal of Arthroplasty Vol. 27 No. 6 June 2012

Each of these components presents a unique challengeto the surgeon if a revision arthroplasty is required.In this audit, we examined the quality and complete-

ness of documentation of key operative informationand components used during primary THA in patientswho subsequently went on to require a revision THA.We reviewed the operative notes for only the infor-mation that would be necessary and helpful for a revi-sion procedure.

MethodsThis study was approved by the institutional review

board. The study cohort was generated by querying ourinstitutional joint arthroplasty database for all patientswho underwent revision hip arthroplasty (THA) by onesurgeon from April 2008 to July 2011. Two hundredthirty-five revision hip arthroplasties were performedduring this period, and of these cases, operative reportsfrom primary THAs were available for 98 patients, asthey were obtained from the outside hospital andscanned into our electronic medical record or the sur-gery was performed at our institution.Primary arthroplasties were performed at both our

institution and outside, nonaffiliated hospitals betweenApril 1986 and April 2011. Operative notes from pri-mary hip arthroplasties, if available, were retrospectivelyreviewed for the following items: (1) date of surgery, (2)preoperative diagnosis, (3) laterality (right or left), (4)procedure performed, (5) surgical approach, and (6)component information. Table 1 shows in detail thechecklist used when evaluating each operative note.We considered the operative note complete if the

dictating surgeon included items 1 to 4 (mentionedearlier) and the type of surgical approach (eg, posterior/posterolateral, direct lateral, anterolateral, or directanterior approach) or described the surgical exposure

Table 1. All Data Points Assessed in Operative Note Survey

Complete List of All Data Points Assessed in an Operative Note

Date of primaryLaterality (R or L)Preoperative diagnosisProcedure performedApproachCup Manufacturer

ProductSize

Liner ManufacturerProductMaterialSizeProfile

Stem ManufacturerProductStem sizeHead sizeHead materialNeck length

of the hip in detail such that the approach could beidentified and included all component information.With regard to component documentation, we dividedspecific component details and dimensions that wereconsidered into individual data points, which weresubsequently put onto a checklist. Each operativereport was then compared against the checklist. Speci-fically, we assessed whether operative notes documen-ted component manufacturer, product, and appropriatedimensions of the implant. For the acetabular cupportion of the implant, we considered an operativenote complete if the manufacturer, product, and sizewere stated. For those implants with a modular liner,we considered a note complete if the liner's manufac-turer, product, material, size, and profile (ie, zero-degree, hi-wall, etc) were documented. Last, weassessed the completeness of femoral stem compo-nent documentation and the information related withthe prosthetic head. To be considered complete, theoperative note must have contained the stem's manu-facturer, product, stem size, femoral head size, and necklength. The prosthetic head material was analyzedseparately, to evaluate the availability of the bearingcouple information.Operative note information was presented using de-

scriptive statistics. Univariate analysis was performedusing the χ2 test for categorical variables to assessdifferences between institutional operative note dicta-tions. The significance threshold was set at a P value ofless than .05.

ResultsOf the 98 operative notes from primary THAs, only 3

(3%) did not state or describe the operative approach tothe hip; the remainder of the operative notes stated ordescribed in detail the surgical approach. All notesrecorded the date of primary surgery, the preoperativediagnosis for primary surgery, and laterality (right or lefthip) of surgery. Table 2 demonstrates the total percent-age of operative notes with incomplete data points.

Acetabular CupThirty operative notes (30.6%) did not record the

acetabular cup manufacturer. Thirty-nine operativenotes (39.8%) failed the document the product type ofthe cup. Twenty-nine notes (29.6%) failed to documentboth the cup manufacturer and the name of the pro-duct. One note incorrectly stated the use of a kneeimplant instead of a hip implant. Only 4 notes did notrecord the size of the cup used in primary THA (4.1%).In total, only 57 (58.2%) of the 98 operative reportsfrom primary THA accurately documented all pertinentacetabular cup information. There was a significantdifference between our institution and the outside

Table 2. Percentage of Operative Notes With IncompleteInformation in Each Category

Percentage of Operative Notes With Incomplete Data Points

Data Point No. of Notes MissingData Point

Notes MissingData Points (%)

Date of primary 0 0.0Laterality (right or left) 0 0.0Preoperative diagnosis 0 0.0Procedure performed 0 0.0Approach 3 3.06Acetabular cup Manufacturer 30 30.60

Product 39 39.80Size 4 4.10

Liner Manufacturer 55 60.44Product 64 70.33Material 49 52.84Size 22 24.70Profile 64 70.33

Femoral stem Manufacturer 20 20.40Product 2 2Stem size 11 11.20Head size 19 19.40Head material 61 62.24Neck length 11 11.20

Previous Operative Reports for Revision THA � Goyal et al 1025

hospitals documentation (72.34% and 45.1%, respec-tively; P b .01).

LinerOf the 98 primary THAs available, 91 primary sur-

geries were performed using implants that had a modu-lar liner (either polyethylene or ceramic). One notedescribed the procedure but did not include anypertinent information regarding the implant used.There was one hemiarthroplasty in our survey. Theremaining 7 surgeries were performed using implantsthat did not require a liner (ie, nonmodular liners). Fifty-five operative reports (60.44%) did not document themanufacturer of the liner, whereas 64 (70.33%) didnot document the product name. The liner materialwas not documented in 49 operative reports (53.84%).Only 22 operative reports (24.17%) were consideredincomplete for failure to document liner size. Linerprofile was the least documented recorded liner dimen-sion, with 64 notes (70.33%) failing to document it. Ofthe 91 primary THAs performed using implants requir-ing liners, only 10 (11%) documented all liner datapoints. There was not a significant difference betweenour institution and the outside hospitals documentation(13% and 8.88%, respectively; P = .5).

StemOf 98 operative notes, 59 (60.2%) were considered

complete and documented all data points relevant tothe stem component. Twenty notes (20.4%) did notdocument the manufacturer of the implant, whereas25 (25.1%) did not document the product. There were19 operative reports (19.4%) that failed to mention boththe stem manufacturer and product. Only 11 operative

notes (11.2%) neglected to document both the stem sizeand neck length. Nineteen operative notes (19.4%) didnot document the femoral head size. This was a signifi-cant difference between our institution and the out-side hospitals documentation (80.85% and 39.22%,respectively; P b .001).The prosthetic head material was omitted in 61

operative notes (62.24%) and the manufacturer in 76(77.55%). Finally, the bearing couple was not identifi-able in 66 operative notes (67.34%). This was a signi-ficant difference between our institution and the outsidehospitals (38.18% and 13.95% of bearing coupledocumentation, respectively; P = .01).

DiscussionDocumentation is a critical part of medicine in the 21st

century. The operative note not only exists to facilitateappropriate medical care of patients after a procedurebut also plays an essential role in audits, billing, medical-legal proceedings, as well as research. In orthopedicsurgery, especially adult reconstruction, the operativenote should ideally function to record the specificdimensions of the various prosthetic implants used soas to minimize any future concerns or complicationsduring a revision procedure. We embarked on this sur-vey of operative notes because it had become clear in theprocess of performing hundreds of revision operationsthat a large percentage of surgeons do not dictatecomplete information from primary surgeries that maybe necessary for the revision operation. To our knowl-edge, this is the first study conducted in the United Statesevaluating the completeness of operative notes in theadult joint reconstruction.The limitations of this study include the relatively

small number of operative notes reviewed, theregional nature of the operative notes (most notesfrom a 3-state radius), and that a large percentage ofnotes (nearly half) were from one institution. Inaddition, using our database, we were unable to verifythe accuracy of the information provided in theoperative report from the index surgery, and thereforecannot comment on this.Deficiencies within operative notes have been evalu-

ated in the past, mostly in the general surgery arena.Flynn and Allen evaluated the use of the operative noteas billing documentation and found that nearly 76%of operative notes contained billing deficiencies, includ-ing incomplete description of the procedure performedand inadequate description of the indications for theprocedure; they also found that nearly 55% of noteswere not dictated within 24 hours of the procedure [6].In a 2000 survey published in the Journal of the AmericanCollege of Surgeons, Moore [7] queried whether facultysurgeons had been given any formal direction or fol-lowed any formal guideline in the dictation of theoperative note. He found that nearly 70% of surgeons

1026 The Journal of Arthroplasty Vol. 27 No. 6 June 2012

reported that they neither received any training indictating operative reports nor did they follow anyguidelines for the dictation of these notes. Shayah andcolleagues [8] evaluated the implementation of theRoyal College of Surgeons Guidelines for operative notesat their department and noted that implementation ofthis guideline for operative note dictation improved thecompleteness of operative notes to nearly 100%, from amediocre 46% of operative notes before guidelineimplementation. Their recommendation was that allsurgical departments use an aide for note dictation toenhance quality and increase uniformity of notedictation. Investigations from the United Kingdom byMorgan in 2009 [9] and Barritt and colleagues in2010 [10] demonstrated that orthopedic surgery pro-cedure-specific operative notes for total knee arthro-plasty demonstrated overall poor completeness andconsistency. The studies established that interventionssuch as surgeon education, use of a checklist posted inoperating theaters and offices, and maximizing the useof computerized procedure-specific electronic templatesthat required entry of all designated information sig-nificantly improved the standardization of the infor-mation presentation and vastly strengthened adherenceto the Royal College of Surgeons guidelines for opera-tive notes.In our survey of operative notes of patients who

underwent revision THA, 89% of operative notes forimplants requiring a liner were missing at least one ofthe items that we defined as necessary for the revisionoperation. Considering that all component informa-tion is readily available during the primary arthroplasty,there is absolutely no reason that the operative noteshould be incomplete in an elective total joint arthro-plasty. In the environment of ever-increasing medical-legal vulnerability of orthopedic surgeons, but moreimportant, for patient safety, it is imperative that weas a profession make it a paramount objective to achievecomplete and correct documentation. We feel that

implementation of a standardized procedure-specificoperative note guideline in each adult reconstructionpractice, with a required implant information section,will minimize incomplete dictations and compel adultreconstruction surgeons to include all relevant informa-tion in their dictations.

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3. Merx H, Dreinhofer K, Schrader P, et al. Internationalvariation in hip replacement rates. Ann Rheum Dis 2003;62:222.

4. Cram P, Lu X, Callaghan JJ. Long-term trends in hiparthroplasty use and volume. J Arthroplasty 2011;11.

5. Recently-Approved Devices [Internet]; c2010 [cited 201107/25/2011]. Available from: http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/default.htm.

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