Accepted Manuscript

The Association between Operative Time and Short-Term Complications in Total Hip
Arthroplasty: An Analysis of 89,802 Surgeries

Peter Surace, MD, Dara acquisition – literature analysis – drafting - critical revision,
Assem A. Sultan, MD, Design – data acquisitions - data analysis – drafting - critical
revision, Jaiben George, MBBS, Design – data acquisitions - data analysis – drafting
- critical revision, Linsen T. Samuel, MD, Design – data acquisitions- data analysis
–drafting, Anton Khlopas, MD, Design – data acquisitions- data analysis –drafting,
Robert M. Molloy, MD, Design – data acquisitions - data analysis - critical revision,
Kim L. Stearns, MD, Design – data acquisitions - data analysis - critical revision,
Michael A. Mont, MD, Design – data acquisitions - data analysis - critical revision

PII: S0883-5403(18)31142-2
DOI: https://doi.org/10.1016/j.arth.2018.11.015
Reference: YARTH 56911

To appear in: The Journal of Arthroplasty

Received Date: 8 August 2018

Revised Date: 9 November 2018
Accepted Date: 12 November 2018

Please cite this article as: Surace P, Sultan AA, George J, Samuel LT, Khlopas A, Molloy RM, Stearns
KL, Mont MA, The Association between Operative Time and Short-Term Complications in Total
Hip Arthroplasty: An Analysis of 89,802 Surgeries, The Journal of Arthroplasty (2018), doi: https://
doi.org/10.1016/j.arth.2018.11.015.

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 ACCEPTED MANUSCRIPT

The Association between Operative Time and Short-Term Complications in Total Hip
Arthroplasty: An Analysis of 89,802 Surgeries

All eight authors listed have been actively involved in the drafting and revision of the

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manuscript contributing significantly to its accomplishment as follows:

Peter Surace, MD1 Dara acquisition – literature analysis – drafting - critical revision -

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Assem A. Sultan, MD1 Design – data acquisitions - data analysis – drafting - critical revision

Jaiben George, MBBS1 Design – data acquisitions - data analysis – drafting - critical revision

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Linsen T. Samuel, MD1 Design – data acquisitions- data analysis –drafting

Anton Khlopas, MD1 Design – data acquisitions- data analysis –drafting

Robert M. Molloy, MD1

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Design – data acquisitions - data analysis - critical revision
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Kim L. Stearns, MD1 Design – data acquisitions - data analysis - critical revision

Michael A. Mont, MD1, 2 Design – data acquisitions - data analysis - critical revision
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Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
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Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY
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Correspondence to:
Michael A. Mont, M.D.
Lenox Hill Hospital
Phone: 216-444-2434
Fax: 216-445-6255
E-mail: montm@ccf.org and rhondamont@aol.com
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1 The Association between Operative Time and Short-Term Complications in Total Hip
2 Arthroplasty: An Analysis of 89,802 Surgeries
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4 Abstract:
5 Introduction: It has been established by previous studies that longer operative times can lead to
6 higher rates of complications and poorer outcomes after total hip arthroplasty (THA). However,
7 these studies were heterogeneous, examined limited complications, and have not provided a clear
8 time after which complications increase. The aims of this study were to: 1) assess whether longer
9 operative time increases risk of complications within 30 days of THA, 2) Investigate the

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10 relationship between operative time and various complications after THA, and 3) identify
11 possible operative times beyond which complication rates increase
12 Methods: The National Surgical Quality Improvement Project database was queried to identify

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13 89,802 procedures that were included in the final analysis. The effect of operative time on
14 complications within 30 days were evaluated using multivariate logistic regression models.
15 Spline regression models were created to investigate the relationship between operative time and

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16 complications.
17 Results: Longer operative times were associated with higher risk of readmissions (p<0.001),
18 reoperations (p<0.001), surgical site infection (SSI) (p<0.001), wound dehiscence (p<0.001),

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19 renal or systemic complications (p<0.001), and blood transfusion (p<0.001). A linear
20 relationship was observed between operative time and readmission, reoperation, SSI, and
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21 transfusions with increased rate of these complications when the operative time exceeded 75 to
22 80 minutes. Venous thromboembolic (VTE) complications had a U-shaped relationship with
23 operative time with the trough around 90 to 100 minutes.
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24 Conclusion: While our findings cannot establish a clear cause and effect relation, they do suggest
25 strong correlation between increased operative time and perioperative complications.
26 Additionally, this study suggests an optimal time of approximately 80 minutes, as a goal for
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27 surgeons, that may be associated with less risk of complications following total hip arthroplasty.
28 Keywords: Total hip arthroplasty, operative time, complications, risk factors
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34 Introduction:

35 Total hip arthroplasty (THA) has witnessed a substantial increase in utilization with an

36 estimated prevalence of 2.5 million procedures in the United States and over 300,000 surgeries

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37 performed each year that is projected to exceed half a million procedures by 2030[1–3].

38 Although the rates of major complications have remained low[4–6], they are expected to rise in

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39 the light of increased usage[7]. Therefore, investigating risk factors that may contribute to

40 developing complications[8] such as increased operative time, is important to surgeons and

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41 healthcare systems. Additionally, this is also relevant to policy makers and quality metrics with

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42 the recent paradigm shift from “volume-based care” to “value-based care”, as longer operative
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43 time is associated with increased hospital resources consumption and may incur substantial

44 cumulative cost to the healthcare resources[9].

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45 Previously, several studies have demonstrated that longer surgical duration is associated
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46 with greater anesthesia-related risks as well as higher rates of wound problems and surgical site

47 infections[10–13]. In patients who undergo THA, higher mortality, venous thromboembolism

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48 (VTE), and neurologic complications have been associated with increased operative time in
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49 several reports that generally had a small sample size[14,15]. Larger studies that collectively

50 reported on all total joint arthroplasties concluded that longer operative time, defined as >240
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51 minutes, was associated with higher revision rates at 8-year follow-up[3]. Similarly, the National
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52 Nosocomial Infections Surveillance (NNIS) guidelines by the Center for Disease Control and

53 Prevention (CDC) recommended a time limit of 3 hours in 1991, stating that operative time

54 should be lower than the 75th percentile[16,17]. However, more recent studies have varied on

55 acceptable operative time, suggesting that an optimal time may be even lower[18].

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57 While previous studies certainly show that longer operative time leads to higher

58 complication rates for THA, the studies have been limited by heterogeneity, low numbers of

59 patients, and incomplete examination of complications. Studies that have attempted to establish

60 specific time criteria are either outdated or incomplete in their analysis of all potential

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61 complications. Therefore, a clear time at which THA operative duration becomes “higher risk” is

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62 poorly defined for today’s arthroplasty surgeons. The aims of this study were therefore to: 1)

63 assess whether longer operative time increases the risk of complications within 30 days of THA,

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64 2) investigate the relationship between the operative time and various complications after THA,

65 and 3) to identify possible operative times beyond which complication rates significantly

66 increase.
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67 Methods:
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68 Data collection
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69 This was an institutional review board exempt study that utilized data from the American
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70 College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database, a

71 publicly available database without direct patient identifiers. NSQIP collects data on
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72 preoperative morbidity, surgical characteristics, and 30-day outcomes for patients undergoing

73 major surgical procedures. In addition, it contains well-defined clinical variables that are
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74 prospectively collected by trained clinical reviewers at over 600 participating North American
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75 hospitals; these data have been routinely audited and have been employed previously by

76 orthopaedic surgery and other surgical specialties[19–22].

77 The NSQIP database was queried from 2011 to 2015 to identify 96,466 primary THA

78 procedures using the Current Procedural Terminology (CPT) code of 27130 (arthroplasty,

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79 acetabular and proximal femoral prosthetic replacement with or without autograft or allograft

80 [THA]). Of these, we excluded 1,547 that had associated periprosthetic fractures

81 procedures[23], 581 simultaneously bilateral THA procedures (with another 27130 CBT code

82 listed for the same admission), 79 conversion THA procedures (CBT codes: 11981; 11982;

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83 27132; 27134; 27137; 27138), and 7 procedures without a recorded operative time. In addition,

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84 the upper and lower 2.5% of operative times were considered outliers and were also excluded

85 (n=4,450 procedures). Therefore, our final analysis included 89,802 procedures. Demographic

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86 characteristics and pre-operative comorbidities were recorded for all patients. Operative time,

87 defined as the duration from skin incision to completion of closure was recorded.

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88 For all patients, the incidence of mortality and readmission for any cause within 30 days

89 were recorded. Reoperation, surgical site infection (superficial or deep), wound dehiscence,
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90 VTE, pulmonary complications (pneumonia, re-intubation, use of ventilator >48 hours),

91 cardiovascular complications (stroke, cardiac arrest, myocardial infarction), renal complications

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92 (renal failure, insufficiency, or urinary tract infection), systemic complications (systemic sepsis
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93 or septic shock), and blood transfusion were also recorded within 30 days of the index THA.

94 These outcomes were all collected by trained reviewers who communicate directly with patients
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95 via follow-up letters or phone calls as well as periodic death searches in public records.
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96 The mean operative times among the various groups were statistically compared using t-
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97 tests and analysis of variance (ANOVA) tests. Multivariate logistic regression analyses were

98 performed to evaluate whether increasing operative time was associated with higher risk of

99 complications. All the demographic variables and comorbidities which showed a difference in

100 operative time at a significance threshold of p<0.01, were included as covariates in the

101 multivariate analysis equation. Therefore, the final multivariate model included the following

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102 covariates: age, gender, race, American Society of Anesthesiologists (ASA) classification,

103 functional status (independent vs partially/totally dependent), smoking, anesthesia (general vs

104 others), obesity, chronic obstructive pulmonary disease (COPD), diabetes mellitus, disseminated

105 cancer, bleeding disorder, and steroid use. With the use of multivariate logistic regression

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106 analysis, adjusted odds ratios along with 95% confidence intervals (CI) were calculated to show

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107 the change in the odds for a complication with every 10-minute increase in operative time.

108 To investigate if there has been a specific relationship between operative time and a

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109 certain complication, operative time was included as a restricted cubic spline term with 4 knots

110 in the logistic regression analysis. Wald statistics was used to assess whether the relationship

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between operative time and a complication was non-linear. Predictive plots of the spline
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112 regression models were created to graphically assess the relationship between operative time and

complications. The predictive plots demonstrate the changes in odds ratios (OR) (the odds of
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114 having an outcome at a specified operative time compared to the median operative time) for the
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115 entire range of operative time. In addition to the visual interpretation of the predictive plots, a
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116 segmented regression analysis with break-point or change-point estimation was performed to

117 identify any possible operative times above which the risk of complication rises steeply. Such
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118 break-points indicate a change in the slope of the relationship between risk of a complication and

119 operative time and were rounded to the closest 5-minute mark for clinical significance. The level
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120 of significance for all analysis was set at p < 0.05. Statistical analysis was performed using R
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121 software (version 3.1.3, Vienna, Austria) [24]. Spline regression analysis was performed using

122 the ‘rms’ package, while segmented regression to identify break-points was performed using the

123 ‘segmented’ package provided with R software [25].

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126 Results:

127 The mean operative time for the entire cohort was 91 ± 30 minutes. The histogram

128 showing the distribution of operative times is shown in Figure 1, which demonstrates a positive

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129 skew with the median time of 86 minutes (interquartile range [IQR]: 68 to 109 minutes). The

130 mean operative times among different demographics is demonstrated in Table 1 and 2. The mean

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131 operative times among those with and without complications are shown in Table 3. Operative

132 time was greater in patients who experienced readmission (95 vs 91 minutes, p<0.001),

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133 reoperation (96 vs 91 minutes, p<0.001), SSI (100 vs 91 minutes, p<0.001), wound dehiscence

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134 (100 vs 91, p<0.001), respiratory complications (94 vs 91 minutes, p = 0.037), renal
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135 complications (94 vs 91 minutes, p < 0.001), systemic complications 102 vs 91 minutes, p

136 <0.001), and transfusions (100 vs 90 minutes, p<0.001). Additionally, multivariate regression
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137 analysis demonstrated that increased operative time was associated with higher rates of

138 readmission (odds ratio [OR]= 1.04, p<0.001), reoperation (OR= 1.05, p<0.001), SSI (OR= 1.09,
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139 p<0.001), wound dehiscence (OR= 1.16, p < 0.001), renal complications (OR= 1.05, p<0.001),
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140 systemic complications (OR= 1.09, p<0.001), and transfusions (OR= 1.13, p<0.001). Increased

141 operative time was not significantly associated with increased mortality (p = 0.526),
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142 thromboembolic events (p = 0.902), respiratory complications (p = 0.148), or cardiovascular

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143 complications (p = 0.773) (see Table 4).

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144 Spline regression models were used to create predictive plots showing relationships

145 between surgical time and complications, as seen in Figures 2 to 4. Using Wald statistics, most

146 complications showed a linear relationship with operative time (see Table 5) including

147 readmission (p= 0.097), reoperation (p=0.499), mortality (p= 0.407), SSI (p= 0.992), wound

148 dehiscence (p= 0.827), respiratory (p= 0.910), cardiovascular (p=0.391), renal (p=0.296), and

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149 systemic complications (p= 0.705). Conversely, Thromboembolic events (p= 0.003), and

150 transfusions (p<0.001) had a non-linear relationship with operative time. Although most

151 complications had an overall linear relationship with operative time, the rate of these

152 complications appeared to increase when the operative time exceeded above 75 to 80 minutes

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153 (see Figures 2-4). The risk of transfusion increased significantly when the operative time

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154 exceeded about 100 minutes (see Figure 3). VTE demonstrated a U-shaped relationship with

155 operative time with the trough around 90 to 10 minutes (see Figure 3)

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157 Discussion:
158 In general, it is self-evident that shorter surgery is attractive for logistic and financial

159 reasons. Additionally, studies have shown that shorter operative times may also contribute to

160 lower rates of perioperative complications. However, current literature examining the effects of

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161 operative time for total hip arthroplasty has lacked large sample sizes, thorough investigation of

major perioperative complications, and establishment of standardized times after which point

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163 surgery becomes less safe. In this analysis, the NSQIP database was utilized to examine 89,902

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164 THA procedures across a diverse set of patients and practices, with careful identification of all

165 major complications. Our results demonstrated a significantly increased rate of readmission,

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reoperation, SSI, wound dehiscence, renal complications, systemic complications, and
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167 transfusions with increased operative duration. Additionally, these data demonstrate a marked

168 increase in many of these complications when the operative time exceeded the 80 minutes mark.
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169 There are several limitations to this study. While the use of a large database is beneficial
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170 in that it allows analysis over a robust sample size, it inherently hinges on the accuracy of the
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171 data. While the NSQIP data are collected prospectively with inter-rate disagreement of only 2%

172 and consistent auditing, it is possible that operative times can be mis-recorded, or the surgeries
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173 were mislabeled in such a large dataset. In attempt to control for this limitation, our methodology

174 included the removal of upper and lower most outliers which most likely represent incorrect
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175 entries. In addition, the diversity of patients and practices captured by this dataset should
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176 decrease the effects of any errors and make these findings still generalizable to the general

177 population. While the comorbidities captured in this data set are extensive, it is important to

178 comment that many aspects of these cases are not accounted for, such as: implant type,

179 complexity of case, use of cement, hospital and surgeon volume, surgeon experience, hospital

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180 teaching status, and VTE prophylaxis. These factors may all effect surgical time and

181 complication profile and are not captured into NSQIP. Nevertheless, multivariable logistic

182 regression analysis was performed which should minimize such confounding effect of several

183 other important external factors. Our data analysis is only up to 30 days post-operatively as

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184 longer-term follow-up data are not available in NSQIP. Nevertheless, we specifically aimed to

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185 examine the relationship between the length of operative time and multiple complications that

186 most noticeably occur in the short-term. Another limitation is that our dataset of

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187 approximately 90,000 cases represent about 6% of the expected 1.5 million cases performed

188 over a 5 year span. Therefore, whether our findings reflect the influence of every

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complication is not clear, despite the use of complex statistical analysis. However, our
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190 sample remains fairly large and we have attempted to control for several factors to reduce

any risk of selection bias. Finally, it is important to note that due to the retrospective nature of
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192 this study and other limitations, our results can only provide evidence of an association between
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193 increased operative time and increased complication rates, not a direct causation.
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194 Previous studies have suggested an association between longer surgical time and

195 anesthetic complications, SSI, neurologic complications, mortality, and VTE[10–15]. These
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196 studies were limited by small sample sizes or incomplete assessment of complications, however,

197 making generalizability and causality difficult to establish. There have, however, been two other
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198 recent larger studies based on the NSQIP database. Wills et al.[26] similarly followed patients
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199 having undergone primary THA from 2006-2015 (103,044 patients). The authors specifically

200 studied infection and DVTs, but other complications were not investigated. As was the case in

201 our study, there was an associated increase in SSI but not DVT with prolonged surgical duration.

202 Additionally, the authors showed approximately 7% increase in risk of SSI for every 10-minute

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203 increase in operative time. This study did not, however, examine other complication rates or

204 establish a true cut-off time. Another NSQIP database analysis by Duchman et al.[18] queried all

205 total joint arthroplasties (THA and TKA) from 2011-2013 for operative time and 30-day

206 morbidity and mortality. Patients were stratified into groups based on operative duration of less

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207 than 60, 60-120, and greater than120 minutes. The authors found increased rates of SSI, wound

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208 dehiscence, transfusion, postoperative sepsis, readmission and reoperation with longer surgical

209 duration. VTE, however, did not show an increase with operative duration. Despite similarities to

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210 the present study, the authors did not separate out THAs from TKAs, making the findings less

211 specific. Additionally, there again was no determined value for operative time and increase in

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complications, with only time groups pre-selected based on authors’ discretion for statistical
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213 comparison. Finally, pre-existing comorbidities and patient demographics were assessed as

independent risk factors and no attempt was made to account for these variables in the statistical
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215 analysis of operative time versus complication rate.

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216 Establishing a time at which point THA becomes “higher risk” is meant not to create a
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217 hard stop point, but to set a standardized goal for the majority of cases. Operative time varies for

218 a myriad of surgeon and patient-related factors, many of which may be non-modifiable. For
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219 example, operative time may be affected by operative settings (hospital volume and type),
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220 hospital staff, surgeon volume and experience, surgical approach, and implant type.
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221 Unfortunately, we are unable to control or stratify for these factors in the current study as this

222 data was not recorded or collected by the utilized database. However, recognizing safest practice

223 and higher risk surgeries based on an established time may benefit the arthroplasty surgeon’s

224 perioperative decision making. One of the largest studies, a review of Medicare patients having

225 undergone THAs, did demonstrate a relationship between longer surgeries and rates of revision

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226 and attempted to establish a cut-off time, which was set at 240 minutes[3]. However, this study

227 did not stratify complication rates beyond need for future revision, and so this time was not

228 based on a complete risk profile. In our analysis, all major complications were examined, making

229 the times more reflective of true risks. Additionally, by excluding “shorter” and “longer”

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230 outliers from our analysis, we establish a more applicable time for the general practice. The

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231 studied time is not meant to rush surgeons or to create a goal time for surgery, as operative time

232 is influenced by many factors. Rather, the 80 minute time equips the surgeon with knowledge of

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233 risk correlation. Similar time values have been established for factors such as body mass index

234 and hemoglobin A1C, and have served surgeons well in identifying higher risk cases and

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improving care. We believe this 80 minute benchmark will allow surgeons to recognize which
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236 cases are more likely to be associated with postoperative complications and to be better equipped

optimize their care. Nevertheless, the authors do not mean to set a new standard of care for the
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238 surgical procedure time, every case has its individual idiosyncrasies.
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239 Our study adds to these previous studies by utilizing a large cohort, examining all major
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240 possible complications, and controlling for pre-existing patient factors to assess a true

241 relationship between operative time and perioperative complications. Additionally, by utilizing
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242 spline models we were able to establish a more contemporary time of 80 minutes, which we
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243 believe is significantly more realistic than previous values of 240 minutes or longer based on our
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244 use of all risk factors and more sophisticated statistical analysis. Interestingly, our study does not

245 support increased incidence of VTE, mortality, or cardiovascular complications with increased

246 operative time, which is similar to the two above mentioned NSQIP studies but contrary to other

247 studies of operative time and complication rates. For VTE, there appeared to be a U-shaped

248 relationship, which may be a product of variation in VTE prophylaxis across practices; however,

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249 this finding may also indicate that when studied over a larger cohort there is not a significant

250 relationship between these factors. The lack of association for mortality and cardiovascular

251 complications in our study may be true, supported by previous studies. However, it may also be a

252 by-product of removing the outlier surgical times from the analysis, in an effort to provide a

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253 more realistic understanding of true risks associated with the majority of THAs.

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254 Longer surgical duration for THA is associated with higher perioperative complication

255 rates in the 30-day postoperative period. While previous studies have provided support for this

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256 hypothesis, they have been limited by small sample sizes, incomplete investigation of

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257 complications, and outdated surgical and perioperative practices. While the authors did not
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258 mean to establish a new standard in procedure time, a time of approximately 80 minutes may

259 help the hip arthroplasty surgeon to identify cases that may be associated with higher risk for
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260 perioperative complications, and thus optimize care and surveillance more appropriately.

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337

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Figure 1. Histogram demonstrating the distribution of skin-to-skin operative times.

Figure 2. Relationship between operative time and A) reoperation rate, B) readmission, C) SSI,
and D) Transfusion. All relationships demonstrate increase complication rates with increasing
operative times. The shaded regions represent 95% confidence intervals.
Figure 3. Relationships between operative time and A) mortality, B) VTE, C) cardiovascular

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complications, and D) systemic complications. All relationships demonstrate increasing
complication rates with increasing operative time, with the exception of VTE, which showed a
U-relationship. The shaded areas represent 95% confidence intervals.

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Figure 4. Relationships between operative time and A) renal complications, B) cardiovascular
complications, C) pulmonary complications. All relationships demonstrate increasing
complication rates with increasing operative time. Shaded areas represent 95% confidence

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intervals.

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Table 1: mean operative time among various demographic groups

Variables Percentage of patients Operative time P-value

(Total= 89802) (Mean ±SD)
Age (years) <0.001
18-44 4.2 101 ± 33

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45-64 43.2 94 ± 31
≥65 52.5 88 ± 29
Gender <0.001

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Male 44.6 93 ± 31
Female 55.2 89 ± 30
Race <0.001

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White 78.5 92 ± 30
Black 7.02 99 ± 33
Others 14.3 82 ± 27
ASA Classification <0.001

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1 4.1 88 ± 30
2 54.7 90 ± 30
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3 39.1 92 ± 31
4+ 1.8 94 ± 32
Functional status <0.001
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Independent 97.3 91 ± 30
Dependent 2.2 95 ± 32
Smoker <0.001
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Yes 13.1 93 ± 31
No 86.8 91 ± 30
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General anesthesia <0.001

Yes 53.7 96 ± 31
No 46.2 85 ± 28
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Table 2: mean operative time in patients undergoing primary THA based on the presence or
absence of various comorbidities

Comorbidity Percentage of patients Operative time P-value

(Total = 89802) (Mean ±SD)
Obesity <0.001

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Yes 51.8 94 ± 31
No 47.6 88 ± 29
Congestive heart failure 0.938

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Yes 0.3 91 ± 31
No 99.6 91 ± 30
Chronic obstructive 0.378
pulmonary disease

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Yes 4 91 ± 30
No 96 91 ± 30
Diabetes 0.010
Yes 11.5 92 ± 30

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No 88.4 91 ± 30
Dialysis 0.217
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Yes 0.2 94 ± 33
No 99.7 91 ± 30
Disseminated cancer <0.001
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Yes 0.2 100 ± 38

No 99.7 91 ± 30
Bleeding disorder 0.018
Yes 2.4 93 ± 31
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No 97.5 91 ± 30
Steroid use 0.010
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Yes 3.7 92 ± 31
No 96.2 91 ± 30
Weight loss 0.635
Yes 0.2 92 ± 32
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No 99.7 91 ± 30
Ascites 0.337
Yes 0.02 99 ± 36
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No 99,9 91 ± 30
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Table 3: mean operative time in patients undergoing primary THA based on the presence or
absence of various complications.

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30-days complications Incidence Mean operative time P-value

Present Absent

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Readmission 3.5% 95 ± 32 91 ± 30 <0.001
Reoperation 1.9% 96 ± 32 91 ± 30 <0.001
Mortality 0.1% 92 ± 34 91 ± 30 0.719

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SSI 1.17% 100 ± 33 91 ± 30 <0.001
Wound dehiscence 0.11% 109 ± 36 91 ± 30 <0.001
Thromboembolic events 0.6% 91 ± 33 91 ± 30 0.883

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Respiratory 0.4% 94 ± 32 91 ± 30 0.037
Cardiovascular 0.3% 89 ± 31 91 ± 30 0.269
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Renal 1.17% 94 ± 32 91 ± 30 <0.001
Systemic 0.33% 102 ± 32 91 ± 30 <0.001
Transfusion 10.8% 100 ± 33 90 ± 30 <0.001
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Table 4. Results of multivariate regression models evaluating the effect of operative time on various
complications

Outcomes Odds ratio* (95% CI) P-value

Readmission 1.04 (1.03-1.05) <0.001
Reoperation 1.05 (1.03-1.06) <0.001

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Mortality 1.02 (0.96-1.08) 0.526
SSI 1.09 (1.07-1.11) <0.001
Wound dehiscence 1.16 (1.09-1.23) <0.001

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Thromboembolic events 1.00 (0.97-1.03) 0.902
Respiratory 1.02 (0.99-1.06) 0.148
Cardiovascular 0.99 (0.96-1.03) 0.773

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Renal 1.05 (1.03-1.07) <0.001
Systemic 1.09 (1.05-1.13) <0.001
Transfusion 1.13 (1.12-1.14) <0.001
*For every 10 minute increase in operative time

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Table 5: using Wald statistical analysis to determine linearity of the relationship between a
complication and operative time. A p-value < 0.05 translates to a non-linear relationship and vice
versa.

Outcomes P-value

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Readmission 0.097
Reoperation 0.499
Mortality 0.407
SSI 0.992

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Wound dehiscence 0.827
Thromboembolic events 0.003
Respiratory 0.910

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Cardiovascular 0.391
Renal 0.296
Systemic 0.705

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Transfusion <0.001
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